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A Scientific Report on Our Evidence Based Treatment of Children with Pervasive Developmental Disorders:

IQ Rise An Outcome That Correlates with Dose of Child Psychoanalytic Treatment: Twelve Preschoolers with Pervasive Developmental Disorder Respond to the Cornerstone Method of Reflective Network Therapy with Cognitive and Clinical Gains

By Miquela Diaz Hope, PhD

 

 

Abstract:

Reflective Network Therapy [formerly known as Cornerstone Therapeutic Preschool Method] has been used since 1965. The current report uses new and old data from the work of Cornerstone teams in three states and five different therapeutic sites. IQ data is available on 117 children, 54 of them RNT- treated, 6 in control and 57 in comparison treatment status. Some surprisingly good results have occurred in an ordinarily difficult to treat diagnostic category of children, those with Pervasive Developmental Disorder. The dose relationship to rise in IQ among Pervasive Developmental Disorder children is our focus. New data is presented on twelve consecutive retested Cornerstone children with Pervasive Developmental Disorder. Twenty-five and thirty three-year follow-ups, including IQ are given on two children who had severe PDD. Control data and comparison treatment data are given, from 6 control children with PDD and 3 comparison treated children given supportive-expressive therapy in a day care center. A combined total of 63 control and comparison children, most not with PDD, and all from or near the same treatment Centers, were also IQ tested and re-tested.

Reflective Network Therapy does not involve medication. It is an intensive in-classroom method of psychoanalytic psychotherapy for preschoolers. It uses a full repertoire of interpretations if the child is able to participate, and is a highly interpersonal and intersubjective treatment. Parents are often in class and guidance sessions are weekly. The child’s entire psychotherapy occurs in classes he attends with other patients, for a combination of education with twenty minutes of individual psychotherapy in the real-life space. Prior reports by other authors associated with Kliman documented that a child’s dose of Cornerstone treatment time correlated with IQ gains among 42 treated children with many diagnostic categories. Since 1995 we have treated and studied an additional series of twelve consecutive children with PDD. Ten were public special education preschoolers treated by the Cornerstone method within their public school classes. The RNT-treated children with PDD show marked rise of IQ, without exception. Children’s Global Assessment Scale rise was also treatment associated but did not show orderly correlation with dose. Once or twice a week RNT psychotherapy sessions produced a one standard deviation rise of IQ. Four or five times a week Reflective Network Therapy sessions produced a two standard deviation IQ rise. Some of the children had multiple psychiatric disorders. Two of the large IQ rise children had PDD plus Posttraumatic Stress Disorder. CGAS and IQ rises did not occur among 6 untreated PDD special education controls and 3 comparison method treated children. IQ also did not rise among summed 63 miscellaneous diagnoses control and comparison children studied and/or treated at the same centers.

Along with others in the field, we consider PDD a brain disorder. Therefore we form hypotheses concerning how psychotherapy using the RNT method activates and develops brain functions in this disorder, resulting in IQ rise.

Introduction:

This is one of a series of reports on full-scale IQ gains among preschoolers treated by Reflective Network Therapy (Kliman 1978, Zelman 1985, 1994, Diaz Hope 1999). The patients have been studied clinically and by IQ testing as preschoolers, and then again after at least eight months of Cornerstone treatment. This report will focus on a subset of 12 prospectively studied children with Pervasive Developmental Disorder. Adding our series of 12 new consecutive PDD cases to Zelman’s earlier retrospective (archival) reports on 42 New York Cornerstone patients with miscellaneous diagnoses who had IQ follow-ups, there are now IQ follow-ups on 54 twice-tested RNT children.

We also report on IQ results in 6 new control PDD special education cases and use a sum of all comparison IQ outcome data, totaling 57 children with various diagnoses treated by other methods at the same centers. For 11 of the California children with PDD we have added a prospective study of clinical progress (Children’s Global Assessment Scale).

The IQ rise results do not seem to depend on any one therapist’s, supervisor’s, educator’s or team’s influence or skills. Five different RNT therapists and their associated teams of teachers were involved in the newly reported PDD treatment, control and comparison cases, at five administratively very different sites, in three cities (San Mateo, San Francisco, Norman) in two states (California and Oklahoma). The California children include 10 unselected consecutive entrants to a public school Cornerstone special education class. Six consecutive control California special education preschoolers with PDD entered a class elsewhere in the same school system. We also report on three comparison method California preschool children, treated at a Salvation Army shelter daycare class for homeless children. Two had PDD, one had PTSD. They received non-interpretive, supportive-expressive individual treatment in the class, plus parent guidance, not Reflective Network Therapy's interpretive psychoanalytic treatment. One Oklahoma child with PDD is included.

Other comparison children were 45 individually treated foster children, mainly under school age, who had various diagnoses, none with PDD. Treatment, IQ testing and retesting among non-Cornerstone treatment projects was carried out from 1978 to 1997 by colleagues (Zelman, Schaeffer, Abrams, Samuels, Friedman, Pasquariella) at two widely separated centers. Their various projects - other than Cornerstone -- indicated IQ generally does not rise or fall as an outcome measure with individual child psychotherapy methods with non-PDD children (N =57) treated 1978 to 1997 by the same or similarly qualified staff. Now, using prospective means, we find full-scale IQ also does not rise with special education preschool PDD children whose testing began during 1997 (Diaz Hope, 1999).

In this report we briefly describe Reflective Network Therapy [aka The Cornerstone Method] used as  described by Kliman in 1968 and 1970. It is an in-classroom intensive application of child psychoanalysis. Delivered in a way individualized to the needs of each child, it includes weekly parent guidance by teachers and multi-weekly psychoanalytic treatment by therapists. The children’s psychotherapy sessions are given only within their real life school classes. The children are never taken out of their groups or classrooms into offices. From the child’s point of view, delivery of therapy is part of their network of care, either within public school special education classes or private agency therapeutic preschool classes. The combination of education, parent guidance and therapy integrated within the child’s daily life space appears modifiable to suit a wide range of preschool patients.

Because the public school special education IQ measures were blind, prospective and controlled, as well as being supplemented with blind CGAS ratings, the inclusion of the new California subset improves methodologically on prior retrospective and uncontrolled studies of the treatment outcomes. Because of the focus here on a reasonably homogeneous diagnostic subset, we include two PDD cases whose follow-up tests results became consecutively available from nonpublic school cases. The eleventh testable child was tested independently at a nearby clinic. The twelfth child was treated by an independent Oklahoma group led by Morris, and tested in Oklahoma.

A great deal of individualization is possible and occurs within Reflective Network Therapy sessions. This allows effectiveness with children having disorders as different as Pervasive Developmental Disorder and Posttraumatic Stress Disorder. PDD is ordinarily unresponsive to psychoanalytic methods. We therefore continue to have the sense of being involved with a valuable psychoanalytic derivative. The method’s properties and effects on individual children within groups of intensively treated patients are just beginning to be explored. Reflective Network Therapy now seems to also provide a practical means of mental health service delivery in a widely available situation, public special education preschool classes, for a clinically very needy population. School systems are naturally interested in intelligence and educability. Therefore we are interested also that an educationally relevant effect, IQ rise, is emerging in a robustly quantified fashion.

Deliverability and efficacy for the past six years in California public school special education classes suggests the method has public health utility. At this time a nation-wide need for treatment of PDD is recognized by federal legislation. Support is mandated for necessary mental health services for emotionally disturbed children, right in their schools.

We leave many topics for later exposition. These postponements include in-depth case reports, the nature and content of interpretations made to children with developmental disorders, correlations of subcategories of diagnoses with outcome, and other considerations which may be relevant to explaining the IQ rise. We will only later explore hypotheses regarding the central role of transference love, transference attachments, countertransference processes, and the intersubjective, intrapsychic, developmental and neurophysiologic layers of events we believe must be considered to account for the IQ rise phenomenon in children treated with Reflective Network Therapy.


History and Rationale for Our Use of IQ As An Outcome Measure:

Why do we report on full-scale IQ changes as an outcome measure in a psychotherapy? There are multiple theoretic and empirical reasons. IQ is low among PDD children (Chakrabarti 2001), of whom almost a third are in the retarded range. Empirical evidence shows that low IQ predicts theory of mind problems (Buitelaar 1999) in children with PDD. Controversies about the value of I.Q. as a correlate of vocational and economic achievement are substantial, but probably we should consider a two standard deviation rise in IQ (as occurs in many Cornerstone cases) as likely to result in interpersonal, academic and vocational success (Goldstein and Mansky 1995, Clement 1984).

What does IQ measure? Theoretically, IQ measures a broad variety of brain functions. Intelligence Quotient (IQ) is a global and complex measure of many mental functions including consciousness, memory, vocabulary and fund of information. IQ is such brain-near data that IQ scores deteriorate in an orderly with magnitude of brain pathology. Even the normal variation of volume of parts of the brain substance literally has some correlation with normal variation of IQ. MRI studies of 85 normal children ages 5 to 17 years using advanced image analysis show brain volume covaries with IQ in total and area-related ways (Reis, 1996). Particularly correlated is the volume of cortical grey matter in the prefrontal region. Subcortical grey matter also contributes to the variance in IQ, although to a lesser extent than cortical grey volume. Psychometric instruments measuring brain intactness correlate with IQ (Reitan 1985, Knights 1991). Still, the use of the WPPSI-R IQ is necessarily a narrow sampling of the brain’s most complex adaptive achievements.

Gardner (1993) points out that the broad construct of intelligence "entails the ability to solve problems or fashion products that are of consequence in a particular cultural setting or community… the creation of a cultural product is crucial to such functions as capturing and transmitting knowledge or expressing one's views or feelings …products range from scientific theories to musical compositions to successful political campaigns”. It is described by Gardner as a "biopsychological potential". Gardner’s theory of intelligence posits that there are seven intelligences that may be evidenced: musical intelligence, body-kinesthetic intelligence, logical-mathematical intelligence, linguistic intelligence, spatial intelligence, interpersonal intelligence, and intrapersonal intelligence. They almost always occur in combinations and overlaps.

Environmental changes can lead to marked IQ rise or fall, including the way a child is psychologically nurtured by family and community, (Skeels 1939; Money 1983, Diaz Hope 1999) and how he or she is educated ( Barnett 1985) . We think that an in the preschool years an intensive, dialogic, affectively powerful and intersubjective therapy such as psychoanalysis whether or not in a group setting may produce changes in brain functioning. This kind of IQ improvement we see in Cornerstone with psychoanalytic psychotherapy may involve some functions changing in the opposite direction from the affect regulating and attentional dysfunctions seen in PDD. We suspect that therapeutic brain functional changes would also be in the opposite direction from the affect regulating, attentional, short-term memory deficits and information processing disorders seen in PTSD (Bremner 1995, 1997). There are neurophysiological studies giving hope that the improvements we see in I.Q. among our Cornerstone children will some day be demonstrable as cortical neuronal and synaptic growth. Such indicators of treatment response are seen with psychotropic treatments, in Prozac-treated mammals (Gross 2000). It has recently been learned that even without treatment, brain neuron growth occurs throughout life among mammals. Neuronal growth is the physiological opposite phenomena of the neuronal death (apoptosis) problems associated with atrophy of hippocampal region, seen in stressed animals and adult PTSD victims (Bremner 1995).

Because IQ is usually well below average in PDD and 25% of the children with PDD are mentally retarded (Chakrabarti 2001), rise of IQ may be a particularly disease-specific measure to study as an outcome in PDD. Cognitive deficits are among the most common and serious sets of pathologies in PDD. They are IQ measurable. The relational problems of children with PDD even affect IQ testability, especially in untreated children. Testability in itself is sometimes an index of improvement. PDD includes difficulty in allowing interpersonal transactions such as staying in one place and collaborating in testing, resistance to many requests, lacking a theory of the mind of the tester, experiencing distress upon change of situation or topic, undeveloped receptive and expressive language and associated attentional and learning disability. We are impressed that testability and testable IQ can grow with salutary environmental influences, just as our review below shows it can decline with psychological trauma, psychiatric illness and physical toxic disorders.

IQ can be measured early. Children as young as three years can be reliably tested by the WPPSI­R (Wechsler Preschool and Primary Scale of Intelligence - Revised) method. IQ is scored by age adjusted means, and WPPSI-R scores are usually stable when retesting is done up to age seven (Hope, 1999). IQ has the useful quality of stability within a given subject, varying little during retesting under ordinary circumstances. The natural history of stability of intellectual performance among individuals in the general child population has been well documented by Moffit (1993) who reports on the reliability, magnitude and meaning of IQ change using scores on the WISC--R obtained from a representative sample of 794 children at ages 7, 9, 11 and 13. Goodman (1978) showed IQ was more unvarying than usual among the 289 children she studied between ages three to nine who had developmental delays.


Objectively Studying Outcomes of Psychoanalytic Child Psychotherapies:

When following psychoanalytically with psychiatrically ill children, some investigators have used nonprojective ratings and measures. Fonagy’s use of the CGAS as an outcome measure, and his remarkably quantified work on reduction of need for insulin among diabetic children in psychotherapy, are excellent examples of objective measures. (Fonagy 1994, 1996). Heinicke’s 1967 work on developmental progress related to dose of classroom group treatment is similar to our own work. It is systematic and highly relevant but his use of the concept of development was not instrumentally ready to be quantified.

Among adults, the objective measure of longevity to age 76 has been shown to be related to IQ (Whalley 2001). Adult physical health (Duhrssen 1972), relative freedom from hospitalizations, and longevity have all been shown to increase as an outcome of psychoanalysis (Doidge 2001). However, IQ change has not yet been well studied as an outcome of either adult or child psychoanalysis.


IQ and Pervasive Developmental Disorder:

IQ itself has previously been studied as an outcome measure in Pervasive Developmental Disorder (Lovaas, 1987; Smith 1997). PDD is probably, as stated earlier, a brain disorder. Our review, below, of scientific literature shows that low IQ and progressive fall of IQ are phenomena closely associated with the extensiveness of some organic brain disorders. Our use of the opposite phenomenon -- rising IQ -- as an objective outcome measure stems from the senior author’s view that PDD is a brain circuitry and function disorder involving attachment and affective processing. We believe it is treatable to some extent by psychological means which literally stimulate, exercise and thus grow the neuronal synapses and circuitry that remain available. Similarly, cerebral palsy is a brain motor disorder that can also to some extent be rehabilitated by exercise of the circuitry and muscles remaining. It is also meant in the sense that neurogenesis can hypothetically be encouraged by stimulation through psychophysiological means. We view RNT psychotherapy as potentially having some of the same effects as psychotropic medications, which are shown to stimulate mammalian brain neurogenesis (Gross 2000).

The view that IQ rise is a sign of rehabilitation and growth among some seriously disturbed Cornerstone treated children, not only those with PDD, is over 35 years old. It stems from Kliman’s at first accidental findings in "Cornerstone" (Reflective Network Therapy classrooms) in the 1960’s and 1970’s, observing the RNT therapeutic nursery to be a cognitively and clinically effective for preschoolers (Kliman 1968, 1975, 1978, 1982, Lopez and Kliman, 1980). That children grew brighter did not seem surprising, because we knew that a Head Start, preschool or day care environment also could influence full-scale IQ. Barnett (1995) summarizes the several trends of decades of early childhood program research: 1) participation in early childhood programs can result in IQ gains of about eight points immediately after completion of the program. The Head-Start IQ gains persist until the children enter school, but diminish as they progress through the early grades (while the scores of control children rise in response to the stimulation they encounter in the school environment) and 2) children who attend the programs are less likely to be placed in special education classes and/or retained a grade and are more likely to graduate from high school.


What Causes IQ Changes Among Children?

We do not question that IQ has a genetic foundation or basis. We are concerned here with what allows or causes changes from that basis. There are numerous studies of causes and antecedents of IQ rise and fall. The effects of breast-feeding on IQ are dose related. Systematic studies of children who have breast-feeding for greater than three months (Angelsen 2001) show the experience correlates with higher WPPSI-R at five years than for children breast fed for three months. Later childhood is not without plasticity regarding IQ. Studies of foster children and children adopted between ages four and six years show marked IQ advantages on follow-up of the foster children and adoptees whose environment is that of a high rather than low SES family (Kliman et al 1982). A high SES family induces a 19.4 IQ gain versus a 7.7 points gain for low SES family adoption (Duyme et al 1999). There also has been a marked and worldwide secular trend to rise of IQ, well documented in 14 economically advanced nations over the past half century (Flynn, 2000, Lynn et al 1987). The increase has been in supposedly culture-free “fluid intelligence”, the mental power that underlies the acquisition of cognitive skills, rather than in crystallized intelligence, which represents the cognitive skills acquired in a particular culture.

Drop of IQ is a grim, highly studied indicator and orderly correlate of the physical extent of cerebral pathology. IQ decline correlates with loss in MRI-measured cerebral volume (After et al 1996, Kornhuber et a; 1985). It correlates with the deteriorative course of social and individual mental disorder of several kinds. The IQs of urban children, regardless of birth weight, decline from age 6 years to age 11 years (Breslau 2001). The downward shift of IQ is so dramatic among urban lower SES children that it ultimately increases by 50% the proportion of urban children scoring 1 standard deviation below the standardized IQ mean of 100. A negligible change is observed in suburban children. In the same sample, maternal IQ, education, and marital status and low birth weight predicted IQ at age 6 years but were unrelated to IQ change. Growing up in a racially segregated and disadvantaged community, more than individual and familial factors, thus may contribute to a decline in IQ score in the early school years.

High quantity of harsh discipline with low quantity of warmth is associated with lowered IQ (Smith 1997). Smith’s sample for analysis consisted of 715 children who were 3 years of age. Multivariate analysis of variance was used to examine the consequences of the mother's harsh discipline on a child's IQ. Maternal harsh discipline in a context of low maternal warmth was associated with IQ scores for girls that are 12 points lower than the IQ scores of girls who received low punishment and high warmth.

Among widespread organic causes, HIV infection of the brain causes a drop of children’s IQ. More fortunately, AZT treatment of HIV encephalitis in children causes a notable rise of IQ. (Pearson 2000, DeCarli 1991)). IQ drops occur in an orderly way in still other conditions when brain functions are interfered with by organic disease. Correlating with of severity of central neurological disorders, IQ drop correlates with brain substance volume shown by cerebral MRI and SPECT data among glue sniffers. Solvent toxicity effects (Yamanouchi et al 1997) among 25 chronic solvent abusers show significant correlation between cerebral white matter loss as well as pontine volume loss and lowered WAIS IQ. Suggesting that IQ depends on a broad spectrum of brain areas, the quantity of therapeutic radiation given to children’s skulls for treatment of tumors (Cousens 1988, Grill 1999, Fuss 2000) has remarkably orderly correlation with the amount of IQ decline. The amount of phenylalanine in diet correlates linearly with decline of IQ among 599 phenylkenoturic children whose diets are relaxed. For each 300 mumol/l rise in average phenylalanine concentrations for those aged 5 to 8 years, IQ at 8 years fell by 4-6 points (Smith 1991) significant up to 10 years of age.

In adults, the correlation of IQ and brain function is shown in the decline of full-scale IQ in Alzheimers. IQ drop significantly predicts the parietal flow deficits found by MRI studies of Alzheimer’s disease (Keilp 1995). Lowered IQ correlates with decreased glucose metabolism in all the grey matter regions measured after strokes (Doi 1991). In children, longitudinal studies shows there is a progressive IQ depressing effects of fragile X disorder. (Fisch 1996), and IQ varies with dose of lead poisoning (Wasserman 1997). Serial measures of IQ in childhood, adolescent and adult schizophrenia show a drop over time (Gold 1999), which is especially associated with “negative” schizophrenic symptoms. Drop of IQ from age four years on is a specific and powerful predictor of psychotic symptoms at age 23, (Kremen 1996). Chronic or severe abuse of children is associated not only with failure to grow in height and weight or thrive, but with lowered IQ and the IQ decline, like height and weight stunting, and the decline reverses with good foster care treatment (Money 1983, Carey N 1995).

The opposite of trauma and disease - the outcome of induced improvement in health - is also worth following with IQ as a cognitive measure. The world-wide culture-free improvements in IQ (comparable to gains in height and weight) over the past few generations (Flynn 2001) probably reflect global improvements in general child health, nutrition and emotional care over time within the societies whose children were studied. Within an individual, we think IQ growth often reflects general improvement of a developing patient, like the reflection in a CGAS rating.

Only a few studies of psychotherapy outcomes have focused on the possibility that favorable environmental or psychological influences might lead to measurable changes in IQ. If psychotherapy improves many of the brain’s functions- such improvements might include a psychometrically notable growth in IQ. IQ change could be due to many treatment factors. Some might be neurotransmitter related, or due to other kinds brain-substance or physiology changes, but possibly. When personality, mood, adaptation and cognition change with treatment, we are likely dealing at least with brain changes of a functional nature. Reduced anxiety, increased attachment to teachers, increased motivation to learn, improved collaborativeness, receptivity, attentiveness, diminished oppositional defiance, reduced pathologic vigilance, increased sense of futureness, increased desire to please, as well as improved registration, encoding and retrieval of information, improved secondary process, enhanced reality testing, and increased energy levels - these are just a few of many high level functional processes which would likely lead to IQ test score gains from successful psychotherapies.

We are increasingly considering a parallel theory of organic possibilities underlying such psychological changes (Kliman, 1999). Nowadays, we are encouraged by psychosomatic data from others (reviewed by Doidge 2001) who find psychotherapy leads to improvements in the health and reduction in the mortality rates. We can still only wonder about the effects of psychotherapies on neuronal viability, kindling, pruning and growth of neurons and connectivity processes themselves. The reduction of stress related hormones and increase of favorable neuronal growth factors could possibly be at work in psychotherapies (Gross 2000).

Neuronal death (apoptosis) and measurable atrophy of specific parts of the brain are now thought to be the result of chronic posttraumatic processes (Bremner, 1995, Kliman, 1999). Thus it is possible that a protective, biologically constructive effect could be at work during some psychotherapies, particularly with highly stressed or highly stress sensitive and still developing patients such as our preschoolers are. For all of these reasons, we wish to bring IQ data into consideration as brain-near measures of outcomes. We think it would be scientifically remiss to do otherwise in dealing with the presumably plastic minds and brains of preschool child psychotherapy patients.

Since the mid 1940s, at least thirteen, longitudinal studies of social environment included IQ as an outcome variable. All report finding that IQ scores can be highly unstable, evidently due to the effects of environmental factors (Bayley, 1955; Bayley & Schaefer, 1964; Bradway, 1945; Bradway & Robinson, 1961; Honzik, Macfarlane & Allen, 1948; Kagan & Freeman, 1963; Kagan, Sontag, Barker & Nelson, 1958; McCall, Appelbaum & Hogarty, 1973; Moriarty, 1966; Rees & Palmer, 1970; Sontag, Baker & Nelson, 1958; Wiener, Rider & Oppel, 1963; Pinneau, 1961). A major, longitudinal study showing IQ changes with personal experience was completed by Honzik, Macfarlane, and Allen in 1948. Individual IQ tests were administered annually to more than 252 children at specified ages over a 16-year period from 21 months to 18 years. These children were a representative sample of the children born in an urban community during the late 1920s. This group was then divided into two matched subsamples of 126 children on the basis of socioeconomic factors. Significant correlations occurred with “environmental characteristics” defined as life experiences that fluctuated between “disturbing” and “satisfying”. IQs changed 15 or more points for almost 60% of the group: IQs changed 20 or more points for almost 33% of the group, and IQs changed 30 or more points for 9%.

Distinct from early educational and child-care intervention programs or naturalistic observations of the effects of social conditions are therapeutic/psychodynamic programs targeting the 2-5 year old age range. Despite the relative lack of IQ outcome studies of psychotherapy and psychoanalytic treatment effects on IQ of pre-school and elementary-aged children, there are several examples of IQ testing pre-intervention and post-intervention which preceded any studies of Reflective Network Therapy. Three studies combined show that eight out of fifteen children showed IQ gains. Of the eight children, only three cases involved long-term treatment and only two involved long-term follow-up (Axline, 1949; Bernstein & Menolascino 1960; Woodward, Brown, & Bird, 1960).

IQ findings of a scale similar to those in RNT ("Cornerstone Therapeutic Nursery") reports were noted by Harris et al (1991). Harris’ preschool children with autism and their normally developing peers were compared on the Stanford-Binet IV and Preschool Language Scale before and after one year of schooling. Both measures showed that although the children with autism continually functioned at a lower level than their normally developing peers, the children with autism had narrowed this gap after a year of education, making a nearly 19-point increase in full scale IQ and an 8-point gain in a “language quotient”.

Goodman (1984) showed that mentally retarded children treated intensively by various psychological means in a hospital clinic had IQ rises. Review of other psychotherapeutic treatment literature on preschool children suggest reversibility and perhaps neurodevelopmental plasticity is present, even in disorders as serious as autism, or PDD with autistic features. Favorable psychological change and growth can evidently occur. More recently, the Lovaas Method, which we consider a real-life space treatment, applicable at home and school, has also had some good results with PDD children. So far, no measures of CGAS but some encouraging developmental quotient and WPPSI IQ outcomes have emerged (Lovaas 1987, McEachlin 1993). The Lovaas method provides an intensive interpersonal attachment experience, often with one aide assigned to “shadow” a child for 40 hours a week. Lovaas studied baseline and outcome developmental quotients and translated them into IQ equivalent data. Field (1977) also reports that developmental delays among three-year-old children have a good prognosis, associated with IQ gains, if the delays are primarily of expressive and receptive language.

Reflective Network Therapy with IQ Studied as an Outcome Measure:

Kliman first noted the cognitive rise phenomenon when in a pre-publication review Anna Freud (Newman, 1970) commented on quotes from the child in “the Case of Jay” (a section in Kliman 1970) as containing very adult-like verbalizations. He began to note several RNT-treated children becoming even more surprisingly bright both emotionally and cognitively. Some were emerging from dismal intellectually unreceptive states of autism and associated mental retardation. In 1966 Kliman first saw an untestable autistic girl among his patients. She was remote, without eye contact, avoidant of change, intensively sensitive to separation from her mother, flapping, twirling, biting, scratching in occasional rages, avoidant of others and almost mute except for singing a soap commercial. She was first diagnosed by two psychiatrists and a neurologist as autistic and mentally retarded. Referred to Reflective Network Therapy in a Cornerstone school at age three she was untestable for several years, during which she was treated daily. In the first year she became able to make eye contact and responded to interpretations of her avoidance and silence as a defense against letting us know she was there. She became calm ceased rages and avoidance of others. Speech emerged with very ratchety pragmatics, haltingly and with very odd prosody. There seemed to be no empathy for others at first. Then after about six months, a rapidly accelerating psychosexual development occurred. Primitive themes of cooking insects and worms were at first important to her, followed by frank urethral competitions. Peeing contests were occasional events with another girl. Oedipal themes were the subjects of simple drawings, soon accompanied by verbalized stories of weddings. By age six, after three years in Cornerstone, she had an IQ of 80. Her full scale IQ kept going up about 20 points every few years. By age twelve her IQ was 148 and she no longer seemed at all autistic! Now at age 36 she is the mother of two children, has an emotionally rich life, and is happily married. She is free of any speech pragmatic difficulties, has a good range of social and successful vocational experiences and has made a videotape with Kliman documenting the considerable detail she recalls of the treatment process.

Having noted this child growing cognitively, as well as few others, Kliman began having Center for Preventive Psychiatry psychologists test other RNT-treated children for IQ as well as keeping abbreviated Hampstead profiles. A presentation (Kliman 1978) was given to Center staff of a series of 12 RNT-treated children showing IQ rises among nine. We thought that IQ rise might be a general brain function stimulating result of early childhood psychotherapy, somewhat the way we conceptualized the IQ raising effect of Head Start. Thus, in 1978 Shaeffer and Kliman incorporated the IQ as a planned outcome measure in a grant application. The study was then carried out from 1978 to 1982 in our NIMH supported project of doing supportive-expressive psychotherapy of either 15 or 40 session total dose with a series of 104 consecutively placed foster children, mainly under age seven years (Kliman, Schaeffer, Friedman and Pasquariella, 1982). There were no IQ findings of significance with those treatment doses. (A four point rise was noted when “intellectually stimulating” and “democratically permissive” foster parents were the caregivers.) Thus RNT therapists at the same Center had a basis for knowing that outside of Cornerstone schools using Reflective Network Therapy, a regular and robust IQ rise phenomenon was not present in our hands. Meanwhile, a set of governmentally supported therapeutic nursery projects similar to "Cornerstone" occurred unknown to us beginning in 1976 under the leadership of Fran Morris in Norman, Oklahoma (Morris 2001). We have her cooperation in performing a long-term follow-up of a treated child with PDD, reported here.

In the 1980’s Zelman, Samuels, and Abrams, who worked with Kliman earlier, looked at IQ changes in RNT treatment archives, Their first published study showed statistically significant results: a mean IQ change of 29.8 points for 9 children receiving Reflective Network Therapy and a tenth child receiving classical psychoanalysis as the major modality. Reflective Network Theraopy was described as requiring “an analytic therapist who worked with the child individually in the classroom in collaboration with the teachers” (p. 217). Zelman, Abrams and Samuels used data going back close to the 1965 origins of the project, although it has not been possible to identify whether they included the autistic girl now age 36 and described above.

In 1994, Zelman and Samuels published a report which expanded the archival research by looking at both the previous group of 9 RNT-treated children and including them in an even larger group of twice-tested children (n = 52) from the same center (p. 340). They found a mean IQ change of 11.7 for 42 children receiving combinations of therapy that included Cornerstone treatment. They included but did not comment on useful comparison data on 10 preschoolers who received only other (non-Cornerstone) modalities and had negligible IQ changes. An exception was a 9 point rise in one child receiving daily psychoanalytic psychotherapy and weekly parent guidance.

Zelman’s archival view of 42 children treated with Reflective Network Therapy is suitable for us to build upon. The children were treated by generally similar, but not identical, psychoanalytically oriented in-classroom means, readily recognizable as the same techniques we used in California. Some Cornerstone videotapes going back to 1967 survive and show methodologic consistency with procedures documented in 1995 to 2000 videotapes. Roles of teachers were kept strictly non-interpretive. IQ became a prospectively studied rather than archival or retrospective focus of data. In California, we included a public school special education classroom as well as having our own nonprofit therapeutic nursery in a community agency.


Modernizing Archival Studies of Reflective Network Therapy:

The "Cornerstone" reports on Reflective Network Therapy outcomes by Zelman et al. (1985, 1994) were very encouraging of further use of the method in California by Kliman. Learning of earlier unpublished observations of Kliman (1999) and Anna Freud (Newman 1970) inspired Diaz Hope to begin the current study of RNT-treated preschoolers. She began using more rigorous, prospective methods and accepted Kliman’s suggestion to add the CGAS (Diaz Hope 1999). In a California public-school based study, Diaz Hope evaluated Cornerstone patients in California being treated by Kliman in 1995-1996 and then a year later by a school psychologist in a San Mateo public school special education class. Availing herself of nearby California special education preschoolers as controls, and supportive-expressive treated preschoolers in a comparison in-classroom group, Hope attempted to replicate the New York private mental health agency findings concerning Reflective Network Therapy.

Zelman et al. (1985) believed that an explanation of their findings was that a “key variable [changed] is [the child’s] anxiety” (p. 223) and its profound lessening. In more detail, Zelman (1985) stated that, especially for a child, it is the “interaction between intensity of anxiety and the development of increasingly reliable and sophisticated mechanisms to regulate anxiety” (p. 223) such that a child is enabled to internalize anxiety-reducing mechanisms of a more adaptive nature. These researchers further hypothesized that the “inhibition of the wish for knowledge in all the pseudoretarded children” (p. 223) is consistent with psychodynamic themes in their treatment along with their remarkable IQ gains (Berger & Kennedy 1975; Bornstein 1930; Buxbaum 1964; Hellman 1954; Klein 1949; Mahler 1942; Oberndorf 1939; Sprince 1967; Staver 1953).

Empirically, the outcomes in all locations using this method have included regular IQ rise. The geographic scope of the appearance of this phenomenon indicates that the IQ rise effect is not due to the particular influence, style or skills of one or another team. Cornerstone method has been in use by at least 20 different teams with at least 700 children in many locations, including three public special education classrooms, since its invention by the senior author in 1965. Private agencies have used the method in White Plains and Yonkers, New York (at The Center for Preventive Psychiatry’s Cornerstone Project), San Francisco (at The Cornerstone Therapeutic Preschool and at The San Francisco, Salvation Army Day Care Center), The Mount Pleasant Elementary Public School in Santa Clara County, CA, The Haight-D’Avila Elementary School of the San Francisco Unified School District, The Early Childhood Education Center of the Office of Education, County of San Mateo, and in perhaps a dozen Federally and State funded Oklahoma Therapeutic Preschools.


Our Choice of Cognitive Measure: The WPPSI-R

The WPPSI-R is an individually administered, norm-referenced, standardized test for children ages 3 years 0 months to 7 years 3 months to assess intelligence. It is organized into 2 groups of subtests, perceptual-motor (performance) and verbal. These yield the Performance scale and Verbal scale IQ scores. These two IQ scales combine to yield a Full Scale IQ, with a mean of 100 and a standard deviation of ±15. The WPPSI-R is a downward adaptation of the WISC-III, which is for children ages 6 years 0 months to 16 years 11 months. The similarities of the subtests between the WISC-III and WPPSI-R (and also the WAIS-III) help measure approximately the same abilities. This is a distinct advantage of using the Wechsler scales, in that the practitioner may compare an individual's abilities over long periods of time. The WPPSI-R has one group of perceptual-motor (Performance) subtests and a second group of Verbal subtests. The child responds to the Performance subtests with motor responses such as pointing, placing or drawing. The Verbal subtests require verbal responses from the child. The WPPSI-R has 12 subtests, 2 of which are optional. The required subtests are Object Assembly, Information, Geometric Design, Comprehension, Block Design, Arithmetic, Mazes, Vocabulary, Picture Completion, Similarities. Two optional subtests are Animal Pegs and Sentences.


Societal Significance of Cornerstone’s Application to Pervasive Developmental Disorder and Other Serious Early-Arising Psychiatric Disorders:

There is multinational concern and notice of the increasing incidence among public school children of early-arising serious psychiatric disorders such as Pervasive Developmental Disorder, especially of PDD with autistic features (Bertrand 2001, Yazhback 2000, California Developmental Services Report 1999). The disorder is usually associated with cognitive impairments and there is a 25% rate of mental retardation among PDD children (Chaktabari 2001).

Diagnosis-free study of behavioral indicators of child psychopathology in general is also showing an increase of other psychopathology in same-age populations sampled over time (Achenbach 1998). The disorders arise early. Not only is the incidence and of serious mental disorders increasing among children, but long term studies show the unfortunate persistence of major early childhood disorders into adult life (Howlin, Mahwood and Rutter 2000). The U.S. Department of Health and Education and the federal government recognize the impact of increasing prevalence and early onset of such disorders on the educability of children. Thus, federal legislation is evolving to keep pace with diagnostic findings and therapeutic needs of children. The Individual’s with Disabilities Education Act (I.D.E.A.) requires not only early detection (“Early Periodic Developmental Screening and Testing” or EPDST) for childhood psychiatric and educationally handicapping conditions. It and mandates therapeutic response literally within the school system itself whenever a child’s educational progress depends upon provision of the most appropriate and least restrictive in-school mental health service. (I.D.E.A. Act of 1987, modified 1997).

Methods which can be individualized to a child’s therapeutic needs and delivered in public school special education settings are sorely needed for educational as well as psychiatric reasons. Practical delivery of service is especially lacking for those thousands of severely emotionally disturbed preschool children with major Axis I psychiatric disorders. Often conspicuous to parents and teachers are those children with Pervasive Developmental Disorders marked by low intelligence, negativism, opposition to learning, avoidance of relationships with teachers and peers. PDD interferes greatly with the children’s receptivity to school procedures and grasp of educational opportunities. If available, treatments for such children would best be given early, as a secondary preventive or public health measure. Early help could hypothetically prevent or reduce the severity of such interferences with acquiring fundamental cognitive and educational tools. Assignment to mental health services which allow the child to be educated could optimally be done by the school when children are screened as they enter public educational systems. Most preferable would be methods which can be delivered in the children’s own real-life classroom spaces, without disrupting the ecology of the children’s lives and schooling.

More restrictive and socially isolating alternatives are to pull the child out of school class for therapy. Providing an aide often removes the child psychologically from learning to deal with peers, and is thus restrictive compared to Cornerstone’s interactive emphasis on relationships with peers. Also more burdensome and unlikely to provide intensive services, are appointments after school hours. It is hard for most families to bring their child to the few appropriate clinics, day hospitals, inpatient units or providing multi-weekly intensive private psychotherapy and guidance. Psychotropic medication treatment is commonly used at preschool ages, but so far there is no report of medication increasing cognitive abilities in PDD. The out of school alternatives to in-school mental health services usually occur only with delays, and are not readily comprehended or assimilated by children with PDD outside of their usual environments. Meanwhile for unreceptive change-resistant, unexpressive and often uncomprehending children with PDD, precious developmental time continues to slip away.


Pervasive Developmental Disorder: Our Theoretic Position

Pervasive Developmental Disorder is a DSM III and DSM IV defined disorder, an often severely disabling condition affecting interpersonal and cognitive activities. It commonly starts to be evident in the second year of life. It is generally considered genetically and neurologically based. The fuller forms of Pervasive Developmental Disorder (PDD) include social, affective, behavioral and cognitive deficits and pathology. At the severe end of its spectrum of social and cognitive deficits, PDD includes autism, in which children have stereotypic movements, flapping, twirling, and self-stimulating activities, narrow ranges of mental interests. Children with PDD, especially with autistic features, are often incapable of socializing, often have difficulty in growing to be self-supporting, tend to be mentally retarded, have little interest in or empathy for most other persons, and lack a theory of the minds of others. There is a high incidence of seizure disorders among PDD children by the time they reach adolescence, and familial, neurologic and genetic abnormalities are being discovered (Lauritsen, 2001).

The core brain structural and functional pathologies in PDD are not yet definitively established, although etiology of PDD and its extreme form of autism are generally considered organic so far as psychoanalysts are concerned. This general view was clearly articulated by Shapiro (1994):

In the U.S. psychiatrists and psychoanalysts, by and large, adhere to the DSM-III-R diagnosis of Pervasive Developmental Disorder, Autism, as a developmental disorder that carries a prognostic implication of seriousness. Outcome studies are available and there is general agreement about the biological origins of this disorder. There is strong adherence to this vantage, even among our few psychoanalytic colleagues who see such cases.

A recent study suggests that the most severe form, autism, is associated with increased brain neurotrophic factor, increased cholinergic nicotinic receptors, and increased cholinergic neurons in the basal forebrain area (Perry, E, 2001). We share the prevailing professional view that PDD is a neurodevelopmental disorder with a poor long term prognosis. As Nordin and Gillberg (1998) state, low IQ level at school entry of a child with PDD is a negative prognostic indicator. The present authors suspect that PDD involves dysfunctions of the orbito-frontal and limbic systems (Schore 1994, 1997) in development of empathy, including neurophysiologically based difficulties in forming a theory of the minds of others and processing affective information during attachment formation. We take the position that such dysfunctions are developmentally very consequential in handicapping the interpersonal relationships which underly all learning, and they involve affective regulation as well as affective encoding of perceived information.

Cornerstone treatment is currently used by the authors for children with PDD to specifically strengthen those brain functions and structures that we believe are still plastic. We take the therapeutically optimistic position that Pervasive Developmental Disorder during the preschool years can still be rehabilitated through interpersonal relations, formal and informal dialogues about learning, creation of semantically encoded mental contents, and practice of affective regulation. In that theory-driven fashion, children in the Cornerstone classroom are given daily emotionally and semantically intensive psychotherapy on an individual basis within the real life-space. That experience necessarily includes practice in mentalizing and processing affects. In Cornerstone, where interpretation of resistance and conflicts within interpersonal relationships is common, children’s positive and negative affects are stimulated by therapeutic transferences, as well as by real-life attachments. The children experience and are analytically confronted with their loves and jealousy concerning teachers and peers. With affectively rich treatment within their real life classroom community, most of the Cornerstone children develop empathic functions, a theory of their own minds, a sense of having an audience in the minds of other people (Barlow 1980).


What The Cornerstone Method of Reflective Network Therapy Is:

Cornerstone treatment is a real life-space method (Redl 1959) of applied child psychoanalysis. Previous publications include case detail showing the in-classroom situation permits an individualized, insight-producing method, based on transferences and using many interpretive maneuvers (Kliman, 1968, 1975, 1997; Lopez & Kliman, 1980, Stedman, 1997, Zelman 1987, 1995). Each child in a group of six or eight patients is treated highly individually by the psychotherapist right in the classroom, and only in the classroom. This happens within classroom activities, amidst the child’s therapeutic education peers and teachers. As we practice the method in California, usually there are two teachers, one therapist and six or eight children in a class, which meets at least three hours daily. Treatment sessions usually focus on the child’s unique here and now issues, such as spontaneous play content, symptoms, drawings, dreams, separation distress, social anxiety, difficulty with cooperation, lack of emotional receptivity, lapses of attention, conflicts over peer relationships, failure to enjoy play achievements, and emotional problems in learning or conforming to classroom rules. Transferences readily develop, and useful interpretations can be made of transference to the therapist. Sometimes a transference neurosis develops and can be analyzed (Kliman 1970) in which the child’s symptoms are more evident in the treatment situation than at home. Influence of peers is often a subject of interpretation, as are the family’s current and historical issues. Resistance to here and now opportunities for the gratifications of learning is especially likely to be an analytic focus. Parents are a regular part of the treatment, are often involved in classroom educational work, and receive weekly guidance.

Teachers have special educational and relational but nonanalytic tasks. The teachers confer with classroom therapist weekly. Teachers are in charge of the classroom activities, with the exception of the content of each child’s daily 20 minute therapy session. Most of the remaining time, each child is engaged in special education activities of a highly socializing and cognitively oriented nature. Often these activities continue themes which are developed in therapy sessions.

In-classroom briefings among the adults, in the child’s presence and with his help, are an essential feature of the method. Teachers give daily verbalized briefings to the psychotherapist about each child’s recent events, behavior and concerns. This is done directly each treatment day, face to face with the therapist, right in the classroom. The briefing occurs with the child’s help strongly encouraged in the process. A briefing occurs immediately before a child starts his in-classroom treatment session. Each child is thus intimately discussed with his own help, in a supportive, nonjudgmental but persistently mentalizing way. Practice of this skill is considered an important feature for all parties to the task.

In the most intensive mode of Cornerstone, each child has a session four or five times a week. Each child’s daily therapy session generally lasts about 20 minutes but occasionally can be varied to be 30 minutes or as short as 15 minutes. Usually the longer sessions are given when a child or therapist has been absent for a session. The time ends with the therapist and child together briefing the teacher about what they have been doing during the session. Other children overhear and often participate, sometimes making remarks or contributing playfully in each others’ sessions. But this is allowed only provided they are willing to let the “index patient” be the one in charge of what is done during his own therapy time. Cornerstone children generally are remarkable for how they jealously prize and eagerly await their turns. As empathy develops, they try to share and allow each other the same privileges and enjoyments of treatment.

The Cornerstone method conducts children’s treatment solely within therapeutic groups run by educators while the therapy is provided by psychoanalytically oriented therapists. Regardless of the reasons for attachment difficulties, the Cornerstone method attempts to create attachments within the treatment process. Indeed, this is an essential basis for Cornerstone treatment. Our approach to children is tailored to each child. In general the Cornerstone staff have a view of language, mentalizing and theory of mind as derivatives of millions of years of the evolution of intersubjectivity among primates. We consider that intellectual collaboration is a derivative of attachment process in terms of achieving mental closeness versus distance, cognitive intimacy versus detachment.

The process used in Cornerstone deliberately includes an enticement to mentalizing rather than behaving. This enticement is through the use of the child’s yearnings to be close with and identify with the analyst. Like a toddler’s parent the analyst is not above attracting a child into a dialogue. In cases of pervasive developmental disorders, mentalizing is crucial to everything else which proceeds thereafter. From the child’s point of view, interpersonal investment is a prodrome of attachment to ideas, and mutuality of interest in the child’s ideas is a prodrome of the child’s attachment to his own mentation. We model an investment in mental life for the child and parent. The three person team of two teachers and therapist show an adult family-like team’scan be attached to a child’s mental life, not only to the whole child. We channel children’s activities and impulses in favor of sublimations of raw action. We use disciplinary methods such as discussion, limit setting, and consequences such as time outs and withholding privileges. We practice waiting to use certain equipment that the child is misusing. Redirection is practiced in many ways, such as offering a choice or suggesting alternative activities such as sexual touching of a doll instead of a peer.

Pharmacologic approaches are not significant in Cornerstone. We do not object to medication, but very few of the children ever receive medication while in our preschool programs. Only one of the last ten consecutive Cornerstone children in our test-retest series was medicated, in his case by a pediatrician. That child had the least rise of IQ in the cohort.

We endeavor, in each case, to develop a highly communicative artificial family to which the child becomes attached. The analyst is a crucial and daily member and part of that family. The family soon becomes real as well as artificial. The artificiality might be defined as a transferential product, but the transactions on a daily basis are real and not identical with transference in regular child analysis. The latter is largely a product of the child analyst being used as a blank screen for projection of the child’s internal world. In Cornerstone, the children are often sufficiently primitive and the treatment so real-life based that the therapist may be witnessing and commenting while a teacher is changing a child’s diaper or when she is moderating a squabble between peers. Furthermore, even the most developmentally advanced children must be given cognitive and socializing education within the classroom, and the Cornerstone therapist is often at the child’s side and commenting analytically on much of the child’s behavior during such educational process. This reality base creates a different kind of transference than if fantasy and history based. Rather than giving his own account of educational and social events, the child’s educational and social events are the subject of immediate shared perception and discussion with the analyst. This may both reduce fantasy as a force in transference and increase reality as a force in transference. It certainly increases the immediacy of the value of the analyst to the child, to have the analyst be there at the child’s side when problems are encountered in the social and educational process.

Fully using and understanding the Cornerstone method requires a theoretical leap from the dyadic realm to the realm of both intrapsychic self-psychology and network psychology at the same time. In the psychological process of the Cornerstone method, the brain and self-representation of the patient stands daily and often at the center of a complex therapeutic community. He or she sees himself reflected in the verbalized and affective realm of peers and adults. The child hears and sees himself discussed with much affect, interest and intelligence by the teacher who briefs the analyst at the beginning of the child's in-classroom psychotherapy session. During this overture, the beginning of a complexly orchestrated symphony of interpersonal expressions and receptions, the child is asked and urged by both adults to participate in the melody and words of the briefing. During this procedure the child receives and, with practice, internally assimilates some of verbalized representation of himself as perceived by the teacher and as perceived by the analyst who comments on the perceptions expressed by the teacher.

The process is more than psychological. Many portions of the mind and brain are presumed to be activated by this procedure, simultaneously investing mental representations with resonating versions of the external emotional environment. It is likely that at least the hippocampus as well as frontal lobes, as well as visual and auditory and interhemispheric communication areas are repeatedly interacting, stimulated, and their pathways potentiated during the Cornerstone briefings. The child basks in the warm and gratifying glow of adult interest and verbalization concerning his person. He is often gladly learning about features of his behavior which are subjects of hostile or avoided communication elsewhere in his life.

Gratified and educated simultaneously the child goes on to play with the analyst for up to half an hour as the index patient. During this time, the analyst and child chat about the child's activities. Only that index patient can take the center stage and no other child is allowed to preempt. Should another child wish to participate, that child must subordinate his play to the themes and activities to the narcissistic interests of the index child. For the sake of having the same privilege, most Cornerstone patients will surrender their own interests temporarily to those of the index child, thus learning altruism and contributing to the mirrored complexity of the mental life of the index patient. Finally at the end of a half hour or so of primacy, the index patient experiences a remarkable and fascinating redundancy of communication. Once more the child becomes the subject of a triadic communication. This time it concerns events that have been closely subjected to verbalization by the team of child and analyst, who now have the task of conveying to the teacher just what they have been doing. The analyst takes the lead and summarizes for the teacher what he in the child have been doing, enlisting the child in the process, drawing upon the child's love for the teacher and his desire for the teachers attention. Perhaps for one of the first times in his life, the child hears himself described intimately and uncritically to an adult dyad. He can use neutral thoughts to contemplate his own self, and to become more adaptive.

Admission of children to Cornerstone is controlled by the public school’s special education administration, with our agreement. In our private nonprofit agency, where we also have a Cornerstone, admission has similar criteria. They are expressed in a brochure which states “Cornerstone’s Seven Admission Criteria” as follows:

  1. Psychiatric evaluation is agreed to or has been provided in written form by a pediatrician, licensed psychologist, psychotherapist, or child psychiatrist. A public school Individual Education Plan may suffice.
  2. Emotional, developmental, attentional, expressive or receptive language disorder has been found.
  3. It has been recommended that optimal education will be achieved if mental health service is included.
  4. Receptive and/or expressive language is above the two year age level.
  5. Stanford-Binet, Wechsler Preschool Primary Scale of Intelligence (WPPSI) or similar IQ testing is agreed to.
  6. Parents or guardians permit professional educational use of videotapes of the child’s treatment.
  7. At least one parent or guardian agrees to participate in weekly guidance conferences.

Very few children are turned away. In the past few years, none have been refused on clinical grounds. The Cornerstone brochure states “Three Exclusion Criteria For Cornerstone Therapeutic Preschool” as follows:

[We have not enforced exclusion category three, and are considering dropping it in light of the present findings.]

  1. Severe autism with no language at age 4 and no sociability for the past 6 months
  2. Persistent or severe dangerousness
  3. IQ or Developmental Quotient probably under 50 and probably not testable by Stanford-Binet or WPPSI protocols within the next few months.

Parents are informed by the same brochure that childhood diagnostic categories for which children’s treatment has been successfully individualized within Cornerstone classroom groups include:

  • Overanxious disorder of childhood
  • Oppositional-defiant disorder
  • Posttraumatic Stress Disorder
  • Pervasive Developmental Disorders, including mild and moderate autism
  • Asperger’s Syndrome
  • Expressive and Receptive Language Disorders
  • Attention Deficit Disorder
  • Psychosomatic Disorders
  • Gender Identity Conflict
  • Adjustment Reaction Disorders (i.e., secondary to Bereavement, Loss of Parental Services, Divorce of other stressor)

With the cooperation of the public school special education system, in the County of San Mateo, we have brought this method into a public health phase in which fee for education or treatment service is not charged. Cost is thus absolutely not an admission issue. For a year, we had our own program in a special education class in San Francisco’s Unified School District. Administrative obstacles to collaboration stimulated us instead to set up our own State certified nonpublic special education preschool in that region. Our agency’s own Cornerstone school in San Francisco has now retested a first child (eleventh in the series) who is included in this report.


Characteristics of The Children in This Cornerstone Data Series:

In keeping with the demand for therapeutic services for PDD within special education classes, all but one of the treated Cornerstone children in the new data were boys who had psychiatric examinations and met DSM IV criteria for Pervasive Developmental Disorder. Most had mild to moderate autistic features. Some were under consideration for other disorders as well, including Oppositional-Defiant Disorder and severe attention-deficit disorder. None were given medication. The average full-scale WPPSI IQ on entry was approximately 70 and the range was from 45 to 108. All 10 San Mateo public school children had Individual Educational Plans (IEPS), complying with federal legislation. The twelfth child, reported on by Morris 2001 from an independent Oklahoma Cornerstone type of treatment, had PDD, with marked autism and moderate mental retardation, with an entry full-scale IQ of 45. Six controls had PDD and were untreated except for their special education, attending their daily special education class in a different region of the same community school system as our public school Cornerstone class.

They were geographically not very far and of comparable ethnic and racial characteristics, of similar SES, and all but two children were Caucasian boys. Expressive and receptive language disorders were present in all of the children. One treated boy with Asperger’s type PDD had marked avoidance, rages, psychotic states, idiosyncratic language, obsessive interest in transport vehicles, and pragmatic pathology in his use of speech and language. He started with a normal IQ of 98. Unlike what Szatmari’s data would lead us to expect, he had a large IQ gain. One girl and boy with PDD, both of whom also had PTSD, each made IQ gains of over 30 points. Expressive and receptive language components to their disorders were present in all of the treated and control public special education children. Two of three of the comparison treated (supportive expressive group) children had PDD, one also had PTSD and one had uncomplicated ADD. All three comparison treated children had marked expressive and receptive language components to their disorders.


Some Characteristics of the Ten California Public Special Education Children,

Six Controls and Three Comparison Treatment Cases:

At the start of treatment, this group of children ranged in age from 3 years to 6.5 years with an average age of five years. At the end of treatment, this group of children ranged in age from 4 years to 7.5 years with an average age of 6 years. Based on the three hierarchical factors of amount of education, type of job and salary, each family received an economic classification: 2-3 out of 3 factors scored as upper class, 1-2 out of 3 factors scored as middle class, and 0-1 out of 3 factors scored as working class. For the total group of children, nine are in the working class, five are in the middle class, five are in the upper class, and one was unknown.

Eight of the children had both parents in the home during the treatment year. Another eight children had one parent living with an extended family member. One child lived with his grandparents and saw his mother on the weekends. Three children were in foster care and had no contact with their birth family. They were cognizant of the birth parents’ existence and had lived with at least one of their birth parents for at least 1 year. Eleven children were considered Caucasian. Six were Hispanic. Two were Black. One was Middle Eastern.

‘External trauma’ was quantified by the presence of the following in each of the child’s school or social service records: physical abuse (including maternal substance abuse during pregnancy), sexual abuse, neglect, general abuse/type unknown, or none reported. Emotional abuse is included in the general abuse/type unknown subcategory. Homelessness as a type of trauma to a whole family is included in the neglect subcategory. Twelve of the children had no reported external trauma in their lives. Five children had both neglect and physical abuse in their histories while two of the children were in the general/type unknown subcategory. One child had experienced physical abuse, supposedly without neglect.

Chronology of Treatment and Data Collection:

Ten IQ testable and then retested children with PDD were treated by the Cornerstone Method within their California public school special education classes, in San Mateo during the years 1995 through 1999. The eleventh consecutive California child with PDD was tested in 2000 and again 2001. She was treated at our own agency’s special education Cornerstone preschool. She had both clinical global assessment (CGAS) and cognitive (IQ) outcome measures. The twelfth new child, an Oklahoma case, had several IQ testings, the first when treatment began in 1976 and the last in 2001.


Children’s Global Assessment Scale Data:

CGAS data was not available from the New York or Oklahoma study in modern form. In the California study (Diaz Hope 1999) a blinded, outside rater scored all of the children according to the CGAS, which is a scale of behavioral, emotional and social functioning.

In looking at the CGAS change scores of the California children with moderate and major psychiatric diagnoses across all groups, there is a significant between the lumped Cornerstone groups and the lumped Control/Comparison group. There are not detectable differences within quantities and frequencies of Cornerstone treatments. The CGAS measures of children with the most problematic behaviors improved significantly in a special education classroom with Cornerstone treatment but not in a special education classroom without Cornerstone treatment. The CGAS change score mean gains were the following: Psychoanalytic Cornerstone = 15, Supportive-Expressive Comparison Group 3.0 and the Control Special Education Group = 0.5
Thus, it would appear that the Cornerstone children improved not only cognitively (WPPSI IQ). They improved significantly in social, emotional and behavorial dimensions (CGAS) as well, and far more robustly than the comparison and control groups. (For fuller information and statistical treatment see Hope, 1999).


Other Aspects of the IQ Data:

Initially, the 12 new treated children had IQs between 45 and 108. Cornerstone treatment produced Full Scale IQ gains significant at the p < .01 level. Cornerstone was more cognitively effective (Full Scale IQ rose with p =. 005) and social behaviorally effective (CGAS rose with p =. 01) for children who had more than one major psychiatric diagnosis. Additionally, the most intensive Cornerstone treatment (four times a week) produced almost twice the amount of cognitive improvement as less intensive treatment. The average intensive therapy result in the San Mateo public school four times a week Cornerstone was a Full Scale IQ gain of 28.75 points, while the less intensive (once or twice weekly) San Mateo public school Cornerstone treatment produced an average gain of 14.7 points (Diaz Hope, 1999, p. 91). The CGAS distinction between Cornerstone and control/comparison subjects was significant at P = .01. But we could not distinguish the CGAS effects of two versus four sessions a week.

Both IQ and CGAS gains both occurred without exception among the new subset of eleven consecutive treated Cornerstone children in California, and an impressive IQ gain (80 points) in the twelfth, an Oklahoma child. The lack of exception to the phenomenon is highly significant. Correlation of treatment dose and IQ rise was most readily studied in the California subset.

Among the prospectively studied ten public and one private special education California children, IQ gains had a dose relationship. IQ gains averaged two standard deviations among patients treated four or five times a week versus one standard deviation for those treated once or twice a week. Treatment was usually for eight months. It appears to be highly significant that the nine California control and comparison treatment children, also blindly rated, had no IQ or CGAS gains.


A Long-Followed Oklahoma Case of Autism with Mental Retardation:

Earlier in this essay we reported on a now 36 year old formerly autistic and retarded Cornerstone child. She gained 68 points from her first testable full score IQ, now has a full scale IQ of 148, and is socially and emotionally very well. Fran Morris (2001) reports a long-term follow-up of the results of an Oklahoma team performing intensive psychoanalytically oriented therapy in the classroom. During 1976 Morris and her colleagues began using an equivalent of the original Cornerstone method, establishing in-classroom intensive therapy programs within therapeutic preschools in several state and federally supported Community Mental Health Centers. At my request, Ms. Morris recently arranged a retesting of an autistic preschooler she had treated by an independently created variation of the Cornerstone method. The boy had a starting full scale IQ of 47 at age 4. There were no doubts about the diagnosis and his mental retardation being part of autism. His IQ at age 8, two years after finishing his therapeutic nursery time was 72. At age 9 years, 2 months, the Oklahoma scored 91. At age 27 his full scale IQ was 125 and he was completing an advanced education. We are hoping that archives of the Oklahoma treatments will yield data of still other retested children, as did the Cornerstone in New York.


Discussion:

Cornerstone psychotherapy uses the whole network of persons in the child’s immediate classroom. It gives PDD children hundreds of orderly and deliberately structured and orchestrated affective experiences during the school year. These experiences, interpreted and verbalized by the analyst, often focus on the child’s behavior in relating to other classmates and to adults in the classroom. The child is literally led to develop a theory of the minds of those multiple others. In the process, the PDD children gain a cohesive view of their own selves as een through the eyes and minds of others, and learn to care and feel for others, while modulating their own affective responses.

It appears the Cornerstone therapeutic classroom is an ecologically flexible environment and the Cornerstone Method is an ecologically effective mental health service delivery system for a variety of disturbed and delayed children. It appears that psychotherapy and parent guidance can be tailored precisely for a child and his family within variegated educational and therapeutic environments. Not all educational and therapeutic teams and systems can sustain such an effort, but notable longevity of the effort has occurred in New York, California and Oklahoma. A large number of diagnostic categories of children have been helped. Expressive and Receptive Language Disorder, Attention Deficit Disorder, Oppositional Defiant Disorder, Posttraumatic Stress Disorder and Overanxious Disorder children have responded well, though no cures are being claimed. Not surprisingly, but conspicuous among those few we recall over the years who failed to show robust improvement are autistic children who were never testable, who had almost no language development by age five, and with little interest in interpersonal relations. Remarkably, some of the best results have been with moderate, mild and occasionally severely impaired PDD children, including some with very marked autistic features. We reported here on two extraordinary long term follow-ups, in which marked rise of IQ was parallel to clinical gains. We think the whole series of surprising clinical and cognitive successes would not ordinarily have happened. They required the Cornerstone Method to make them happen. The in-classroom services involved a helpful synergy of educational influence with psychotherapy and parental guidance, creating an influential social network which targets and compensates for the PDD child’s most underdeveloped functions: tender affective communication, mentalizing of events and behavior, and modulation of social interaction. The same three functions of the social network, particularly the mentalizing function, are highly valuable in promoting more sophisticated forms of psychotherapy and guidance for the much more advanced overanxious, traumatized, or oppositional-defiant children who are also seen to benefit robustly. Most effective of all are the cognitive and behavioral results when a psychoanalytically oriented therapist adheres to a nearly daily schedule of interaction with the children, and meets very regularly and often with parents.
Core features of Cornerstone we think are efficacious are the following: individualizable content of sessions tailored to the child’s own mental contents, high frequency of in-classroom analytic treatment sessions, intensive interpretive work on resistance to socialization and learning in the real life-space, immediacy of the analyst’s and teachers’ mutual briefing and debriefing of the network of patient and his peers and caregivers in the classroom, similar networking of parental involvement in the classroom, and weekly parent guidance sessions. Play therapy literature shows that treatments which lack high frequency, lack an interpretive component, lack a focus on real life-space interpretation of resistance to learning and socializing, or lack intensive involvement of parents are associated with no or markedly less IQ gain and clinical improvement among PDD, other severely emotionally disabled preschoolers, or children stressed by foster care placement (Sokoloff 1959, Kliman, Friedman, Schaeffer and Pasquariella 1982). The highest IQ gains (two standard deviations) occur in the highest frequency of treatment groups, especially those run by psychoanalytic therapists as described by Kliman (1968, 1970, 1997) Hope (1999) and Zelman (1985, 1997).
 
The present California cases, like the long-followed Kliman case and the Morris case from Oklahoma, put together with the 42 Cornerstone cases from New York seem a coherent whole to us. They show the ability of Cornerstone teams in entirely different geographic and administrative settings - East Coast, West Coast, Middle America, public schools and private agencies -- to carry out the method with powerful clinical and cognitive effect. This current research improves on the significance, of the earlier retrospective and uncontrolled Cornerstone method studies of Zelman, Samuels and Abrams (1985, 1994). As with Skeels’ work with adoptees, those earlier reporters generally found an average rise of two standard deviations. Some children have clearly gone much further - as in the two long-followed cases. Skeels experiment, which encouraged close-attachment within an institution for adolescent mothers and their babies, showed an average gain of 27.5 points above control cases for the IQ of institutionalized others’ offspring, (n=13) versus a decline of 26.2 points in the control group (n=12). The various prior reports of IQ rise averaging up to two standard deviations are continued with our current data. Among their treated children: Zelman found a similar average rise of two standard deviations or 29.8 points with intensive (3 to 5 times a week) Cornerstone treatment while there was an average rise of one standard deviation or 11.7 points with less intensive Cornerstone treatment and/or other treatments. For Zelman’s comparison group of 9 children who received only individual educational psychotherapy, without psychoanalytic work, there was only a rise of 4.22 points in IQ, much as in our 3 comparison and 6 control children, who had no IQ rise. It is impressive to us that the largest IQ rises reported are the product of the most intensive treatment, with the highest total dose. This phenomenon is occurring on both coasts and in Oklahoma, each with different supervisory venues, with different administrations, different therapeutic teams and testers, and being found whether studied retrospectively or prospectively, and has probably been happening without our testing and documenting all the cases since 1965.
 
Our still-ongoing six years of public school application of intensive in-classroom methods has produced most of the new data. It comes largely (in ten of twelve new cases) from collaboration with an enlightened public special education department in San Mateo California, administered by Jay Parnes. Our agency is in its sixth year of collaboratively providing mental health service literally within the County of San Mateo’s public special education preschool classes. Follow-up data comes also from the only so-far testable and re-tested child among the seriously disturbed children in our new Cornerstone Therapeutic Preschool in San Francisco. That school has very recently been certified as a nonpublic special education preschool and kindergarten able to contract with surrounding public school districts to treat and educate disturbed preschoolers.
 
The California public and nonpublic special education use of Cornerstone has been clinically, educationally and scientifically rich. The new data resulting has significance in a freestanding way, because of the availability of controls and comparison children, and the prospective method used. The prospective new data is further compelling when considered with the archival New York data assembled by prior authors (Zelman, Abrams and Samuels 1985 and1997) concerning Cornerstone treatment of 42 preschoolers . We expect the legal and political future allows a reliable contractual process between psychoanalytic therapists and school districts wishing to serve their severely disturbed preschoolers in the least restrictive way. Thus upcoming generations of psychoanalytic child therapists may have a significant public health contribution to make in providing classroom based treatment. We look forward to more educationally impaired children being helped overcome mental health obstacles to their education, in this rather unrestrictive way. There is sufficient scientific basis now for treatment of more children with PDD in special education classrooms beginning at the preschool level, rather than depending mainly on aides, medications or pull-out therapies in offices, clinics and residential facilities.


Conclusion:

There are now have a variety of means to consider for judging child psychoanalytic outcomes, including Cornerstone’s outcomes. IQ, CGAS, Hampstead profiles, anecdotal, retrospective, and systematic prospective controlled and comparison evidence all appear feasible. Evidence is robust for very good clinical and cognitive outcomes in seriously emotionally disturbed and pervasive developmental disorder patients. Neurophysiologic studies of the IQ rise process are also in order. It may be that SPECT and similar studies will show the brain effects of Cornerstone therapy. Now that mammalian brain cells are known to continue being formed, and now that we know psychotropic medications can induce neuronal growth, we have some hopes psychotherapy could do the same. We look forward hopefully now to new means of illuminating the neurophysiologic as well as psychological bases for the progress of our Cornerstone patients.

Our final note concerns public health goals. We are encouraged by objective data to continue and disseminate Cornerstone services to preschoolers with PDD as well as those with other serious emotional disorders. We are especially interested to do so in public school special education settings. Inclusiveness and least restriction count ethically and legally. In public school settings the Cornerstone method has proven itself as inclusive and unrestrictive compared to other methods. It has made inclusion in both education and psychotherapy feasible. Compared to isolating therapies or shadowing by an aide, Cornerstone is unrestricting for preschool children with PDD. Some on whom we have reported are children who would otherwise be restricted or excluded from a real school life and could not be expected to benefit much from a mental health service outside of an educational environment.
 

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Appendices publicly available:

 

See video: "Autism Recovery: 33-year follow up" on this website. Permission is granted for public viewing by the interviewee.

 

Other appendices are available to qualified professionals with parental permission for scientific study, research and educational purposes only. (A signed confidentiality agreement is required.)

 

1. An in-classroom view of The San Mateo Cornerstone experience

2. The San Francisco Cornerstone experience.

 

See also: Instructional DVDs

 

 

For more information, contact Gilbert Kliman, MD, Medical Director, The Children’s Psychological Health Center, Inc., 2105 Divisadero St., San Francisco, CA 94115

 

 

 

Contacts Products New!