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Autism & Stubbs Terrace Hospital
When I was nine, I had no understanding of autism, let alone the tentative diagnosis that would eventually be confirmed as my own. I don’t remember other children discussing their diagnoses either. We were more likely to ask each other things like “what are you in for?” or “how long are you in here for?”, and the second question never had an answer anyone knew.
It was only decades later that I realised a surprisingly large number of people I’d come into contact with through Stubbs Terrace, both those I knew at the time and others I’ve since found again, had already been diagnosed with autism, either before they were admitted or while they were there.
Combined with published information about autism services operating within Western Australia’s child psychiatric system at the time, it raises an important question about just how significant autism was within the Stubbs Terrace patient population. Yet there are no publicly available statistics showing how many autistic children passed through Stubbs Terrace, and remarkably little published information about the hospital or the children who lived there at all. At times, it is almost as if we never existed.
That absence is one of the reasons I am filling this gap as part of the Perth History Database.
Autism was still poorly understood
Understanding autism at Stubbs Terrace also requires looking at how recently autism had been recognised as a condition separate from other psychiatric disorders.
The word “autism” had been introduced by Swiss psychiatrist Eugen Bleuler in 1911 but he used it in connection with schizophrenia, rather than autism, as it’s understood today. Soviet child psychiatrist Grunya Sukhareva published detailed descriptions of children with characteristics now recognisable as autism in the 1920s, while Leo Kanner described “early infantile autism” in 1943 and Hans Asperger published his work the following year.
Despite this, autism remained closely associated with childhood schizophrenia and psychosis for decades.
When the first Diagnostic and Statistical Manual of Mental Disorders, the DSM, was published in 1952, autism was not recognised as a separate diagnosis. This remained the case with DSM-II in 1968. It was not until DSM-III was published in 1980 that “Infantile Autism” was formally separated from childhood schizophrenia and recognised as its own diagnosis.
This means that for the first seven years Stubbs Terrace operated, from its opening in 1973 until 1980, autism was still not recognised as an independent diagnosis in the DSM.
That doesn’t mean doctors in Western Australia didn’t recognise autism. In fact, WA had already established a specialist service several years before Stubbs Terrace opened.
The Mildred Creak Centre
In 1968, Western Australia's Mental Health Services established the Mildred Creak Centre specifically for the treatment of autistic children. The centre was named after British child psychiatrist Dr Mildred Creak, an important figure in establishing diagnostic criteria for childhood autism. Perth psychiatrist Dr William Ernest Robinson was involved in establishing the centre and would also establish Stubbs Terrace Hospital for emotionally disturbed children.
The connection is important. Autism services and Stubbs Terrace were not completely unrelated parts of the health system. They developed within the same WA child psychiatric service and shared an important figure in Robinson.
By the time Stubbs Terrace opened in 1973, WA Mental Health Services had therefore already been treating children specifically identified as autistic for approximately five years.
The Mildred Creak Centre later operated from the Edward Millen complex in East Victoria Park.
The Mildred Creak Clinic at the Edward Millen-Hillview Precinct in East Victoria Park
Autism and the W. E. Robinson Unit
The W. E. Robinson Unit was constructed at the former Edward Millen site in East Victoria Park in 1983 and opened the following year as a small six-bed residential unit, initially providing respite and residential care for autistic children. It was named after Perth psychiatrist Dr W. E. Robinson, who had been involved in establishing both the Mildred Creak Centre for Autistic Children and Stubbs Terrace Hospital.
The Robinson Unit did not remain exclusively an autism service. By 1988 it was officially described as a residential therapy unit for children with “cerebral dysfunction and autism”, and by the 1990s it was providing residential mental health programs for children and adolescents with a much wider range of psychiatric, behavioural and schooling difficulties. These included anger-management problems and difficulties associated with attention deficit disorder. The unit also provided week and weekend residential programs, respite for families and practical social and personal-development support.
After Hillview Child and Adolescent Clinic closed in 1995, its inpatient services were progressively transferred to Bentley Hospital, while the W. E. Robinson Unit continued operating. Parliamentary records from 1998 specifically linked the importance of Robinson's weekend residential service with the loss of weekend services at Stubbs Terrace.
A child whose principal treatment was specifically for autism could be referred to Mildred Creak, while an autistic child requiring psychiatric admission, assessment or management of serious behavioural or emotional difficulties could still come into contact with Stubbs Terrace.
The Rotunda Building at the Edward Millen-Hillview Site
How common was autism thought to be?
The number of children officially recognised as autistic at the time was extremely small compared with today. As late as 1992, the WA Government described autism as a “rare” disorder affecting approximately 120 children across Western Australia, based on an estimated prevalence of only four autistic children for every 10,000 children.
The same government announcement described autism principally in terms of extreme social withdrawal and isolation. This reflected the very narrow definition of autism still being used at the time. Children generally needed fairly obvious characteristics to receive the diagnosis.
Children who spoke well, had average or high intelligence, could participate socially to some extent or were able to hide their difficulties were much easier to miss. Girls were particularly likely to be overlooked.
This means the number of children formally diagnosed with autism can’t be treated as the number of autistic children who actually existed. Some children would instead have been diagnosed according to the difficulties they presented with, including intellectual disability, developmental problems, communication difficulties, behavioural disorders, emotional disturbance or psychiatric conditions.
Others may never have received a diagnosis at all. It is a considerable contrast with today, when autism and the idea of “being on the spectrum” have become part of everyday language and self-diagnosis has become increasingly visible, particularly online.
Treating autistic behaviour
The Mildred Creak Centre provides some insight into how autism was being approached within WA Mental Health Services before Stubbs Terrace opened.
In 1969, psychologist Ross Calnan, clinical psychologist Yvonne Atkinson and psychiatrist Dr William Edward Robinson prepared an unpublished progress report titled Out-patient treatment of autistic children: an experiment with operant conditioning, cited in Moffatt (1970).
The unpublished progress report is important because it shows that behavioural conditioning was already being experimentally used with autistic children in Perth only a year after the Mildred Creak Centre opened.
WA Mental Health Services social worker R. A. Moffatt's 1970 article, The Treatment of Autistic Children, also described the establishment of the Mildred Creak Centre and placed its work within the behavioural treatment of autism then being developed internationally.
Operant conditioning works by changing behaviour through its consequences. Behaviour that therapists wanted to encourage could be followed by praise, attention, food, toys, activities or another reward. Behaviour regarded as undesirable could be ignored, interrupted, redirected or otherwise discouraged.
International autism research being considered during this period included attempts to teach speech, imitation, eye contact, following instructions and interaction with other people.
For children who could not communicate effectively, teaching useful speech and other practical skills could obviously be valuable. However, the definition of what constituted an undesirable behaviour was considerably different from the way autism is understood today.
Making autistic children appear less autistic
Autism treatment during this period largely concentrated on observable behaviour.
Rocking, repetitive movements, repetitive play, avoiding eye contact, repeating words or phrases, becoming intensely occupied with particular objects, withdrawing from groups and insisting upon routines could all be regarded as abnormal, stereotyped or socially inappropriate behaviour.
The objective was often to reduce these behaviours while increasing speech, eye contact, imitation, social interaction, appropriate play and compliance with instructions.
Modern understanding makes an important distinction that was often missing at the time.
Teaching a child a reliable way to communicate, helping them develop independence or reducing dangerous self-injury is very different from stopping a harmless repetitive movement just because it looks unusual.
Some behaviours that were once regarded primarily as symptoms requiring correction are now understood as ways autistic people may regulate themselves, communicate distress or cope with overwhelming sensory or emotional situations.
Behaviour at Stubbs Terrace
There is no evidence suggesting that Stubbs Terrace operated its own separate autism treatment program. Its official role covered a larger range of childhood psychiatric, emotional, behavioural and developmental conditions. It opened in 1973 with 15 beds and became Western Australia's inpatient psychiatric hospital, principally for primary school-aged children.
Aside from personal records obtained by a small number of former patients through Freedom of Information before the original files were destroyed after the required retention period, published research into children admitted for what was then described as “gender disorder” provides one of the clearest surviving accounts of day-to-day treatment at Stubbs Terrace.
These research findings demonstrate that behaviour was closely observed within the structured inpatient environment and could become an important target of treatment. Children were encouraged to participate in activities and interact with others, while behaviours regarded by staff as inappropriate or socially isolating could be discouraged, redirected or replaced with behaviours considered more acceptable. A modern examination of one former patient's original medical records and adult recollections also found evidence of psychologically coercive and aversive practices intended to change or suppress behaviour.
These records concern a particular group of children admitted between 1975 and 1980 and cannot be used to claim that autistic children received exactly the same treatment.
They do, however, demonstrate how strongly children's observable behaviour could become the focus of psychiatric treatment at Stubbs Terrace.
When autistic behaviour could be seen as bad behaviour
This becomes particularly important when considering autistic children.
A child experiencing sensory overload may scream, lash out, run away or become unable to respond to instructions.
A child unable to communicate what is wrong may express distress through behaviour.
Another child may become extremely distressed when a familiar routine suddenly changes.
Today those circumstances would raise questions about sensory processing, communication, anxiety, predictability and the child's environment.
During the 1970s and 1980s, the resulting behaviour could instead be recorded principally as aggression, acting out, tantrums, withdrawal, non-compliance, emotional disturbance or unmanageable behaviour. That difference matters. Treating the outward behaviour without understanding what was causing it could result in attempts to stop the child behaving a particular way without addressing why the behaviour was occurring.
For an autistic child living in an unfamiliar psychiatric hospital, separated from their normal home environment and routines and surrounded by unfamiliar children and adults, this could have been particularly significant.
My experience with autism
I couldn't talk until I was seven years old, an age I've since seen mirrored in a number of autistic case studies and in conversations with other autistic people and, particularly, their mothers. During Year 1 at Allenswood Primary School, Mrs Dunbar had me seated at the back of the classroom, well away from the other students because I kept pinching them.
At some point during the first half of Year 1 in 1988, I began attending the Kapinara Language Development Centre at Kapinara Primary School in City Beach and remained there until the end of the year. During this time, I also spent time in a mainstream Year 1 class at Kapinara. I have no idea exactly how my school week was divided between the two.
The Kapinara Language Development Centre formed part of what is now the West Coast Language Development Centre and grew from work begun by educator Marie Donovan in the early 1980s. Donovan had been principal of the Mosman Park School for the Deaf and recognised that there was another group of children who had normal hearing but serious communication difficulties that interfered with their ability to learn in an ordinary classroom. The first specialist language development classroom began in 1982 with one teacher and six children, followed by additional centres around Perth.
Lunch at the Kapinara Language Development Centre.
I'm wearing red pants (obviously!). The boy on the right with the
beautiful smile was my best mate Sam. I really liked him.
Their purpose was to provide intensive teaching to children whose speech and language development was sufficiently delayed to interfere with ordinary schooling. The present-day system still follows essentially the same principle. Children receive intensive language, academic and social support in relatively small groups before transitioning into mainstream classes.
Today, the Department primarily describes these children as having Developmental Language Disorder, or DLD. In the 1980s, that term was not used consistently in the way it is today. Children could instead be described as having language delay, developmental language difficulties, speech and language impairment, communication disorder or similar terms.
The modern admission process involves speech pathology assessment together with assessment of development and adaptive functioning. The aim is to identify children whose primary difficulty is language, rather than language problems caused principally by intellectual disability, hearing loss or another condition.
What is interesting is how quickly things appear to have changed after that. My school reports show that by Year 3 in 1989 I was described as reading confidently and fluently and was “very eager to express herself” in writing, although comprehension and organising my thoughts remained difficult. By Year 4 I was described as “an imaginative writer with plenty of ideas” and by the end of Year 5 I was considered a competent, self-motivated reader and a capable speaker.
The reports also show a considerable difference between different areas of learning. By Year 5 I was receiving the highest performance level for oral and personal reading while remaining below the expected level in mathematics. Across several years there were repeated comments about difficulty understanding what questions were actually asking, organising written information, following instructions, becoming distracted and struggling to maintain attention.
None of those school reports can retrospectively say why I experienced those difficulties, nor was that their purpose. What they do demonstrate is that having extremely limited speech early in childhood did not mean that I lacked the ability to learn. Within only a few years of beginning to speak, I was reading fluently, writing stories, contributing to class discussions and functioning in a mainstream classroom.
Speech and intellectual ability
My own experience is also relevant to the way speech and intellectual ability were historically understood. Autistic children who spoke very little or not at all were particularly vulnerable to being misunderstood. During this period, the ability to speak and respond appropriately to conventional psychological testing could strongly influence assumptions about a child's intellectual ability.
We now know that spoken language, receptive language and intelligence are not interchangeable. Some autistic children who remain minimally speaking for years subsequently develop useful speech, sometimes considerably later than previously expected. Others remain nonspeaking but demonstrate through alternative communication that they understand considerably more than had been assumed.
Historically, however, a child who did not answer questions, follow instructions or communicate in an expected way could easily appear to have much less understanding than they actually possessed. This is particularly relevant to institutions such as Stubbs Terrace, where psychiatric assessment necessarily depended heavily upon what staff could observe.
A similar image to what the Stubbs Terrace Hospital playground looked like in 1990
My own psychological testing
My own results provide an interesting example of why speech and intellectual ability should not necessarily be treated as the same thing. In 1990, several years after I began speaking, psychological testing produced a Verbal IQ of 95 and a Performance IQ of 123. When I was tested again in 1994, my Verbal IQ was 90 while my Performance IQ was 131.
The psychologist described my results as showing average verbal but superior nonverbal ability, with considerable differences between individual tests. The poorer results generally occurred in verbal tasks. In particular, I had difficulty with expressive language and remembering information I had just heard.
The difference became particularly obvious during memory testing. When I was read a list of 15 words, my recall after hearing the list once was extremely poor, placing me at the 10th percentile. After hearing the same words repeatedly, however, my recall improved to the 75th percentile. When information was presented visually rather than only through hearing, my performance was generally considerably better.
My school reports from the same period make repeated references to difficulties following instructions, understanding what questions were asking, maintaining attention and organising my thoughts. The later psychological testing cannot explain every one of those observations but it does demonstrate that the way information was presented to me could make a considerable difference to how well I performed.
This is particularly relevant to children with limited speech. Had my intellectual ability been judged principally by my verbal performance, it would have provided a very different picture from tests that allowed me to demonstrate what I could do nonverbally.
Boys, girls and the autism that was missed
The autism recognised during the Stubbs Terrace period was also heavily influenced by research conducted predominantly on boys.
Autism was consequently associated with children who displayed obvious social withdrawal, repetitive behaviour, unusual interests, communication difficulties and rigid behaviour. Girls could present differently or become better at concealing their difficulties.
Some learned to copy other children's behaviour, rehearse conversations, imitate expressions, force eye contact or attach themselves to socially confident friends. Interests could also appear superficially ordinary while being unusually intense. This later became known as masking or camouflaging. Boys can also mask and girls can have very obvious autism but the historical diagnostic model made some presentations considerably easier to recognise than others. As a result, the children officially identified as autistic during the Stubbs Terrace period probably represented only part of the autistic population.
Autism was not something caused by parenting
Another major change occurring during the lifetime of Stubbs Terrace concerned what doctors believed caused autism. Earlier psychiatric theories had sometimes blamed parents, particularly mothers. The notorious “refrigerator mother” theory suggested that emotionally cold parenting caused children to psychologically withdraw from the world. Research increasingly demonstrated that this was wrong.
My Maman has very bitter memories of Stubbs Terrace Hospital, partly because of her treatment by one of the hospital’s senior psychiatrists, who seemed to blame her for my behaviour and the difficulties associated with my autism, as though these were the result of poor parenting. That bitterness remains today. When I recently told my Maman that the psychiatrist had died in 2015, her response was simply, “Good.”
Family and twin research during the 1970s provided increasingly strong evidence that autism had a substantial biological and genetic basis. Researchers also demonstrated important differences between autism and childhood schizophrenia.
By 1980, the evidence was strong enough for DSM-III to finally recognise infantile autism separately from schizophrenia.
Autism is now understood as a complex neurodevelopmental condition with a strong genetic component. There is no single autism gene and no single cause. Many genetic variations and developmental pathways can contribute to autism, with some prenatal and early developmental factors also associated with an increased likelihood.
The underlying development begins before birth or very early in life. Autism is therefore not something a child develops because of poor parenting, institutionalisation, trauma or being treated badly. It may not become obvious until later, when a child's social, communication and developmental demands become more complicated.
My own medical records provide an interesting example of how complicated the question of what “causes” autism can become. They record that my mother experienced pre-eclampsia during late pregnancy, followed by a forceps delivery under epidural anaesthetic, and that I had mild jaundice at birth.
Some pregnancy and birth complications, including pre-eclampsia, have since been associated in research with an increased likelihood of autism. An association, however, does not mean that the complication caused the autism. Forceps delivery, epidural anaesthesia or mild jaundice cannot simply be identified as the reason an individual child became autistic.
Rather than there being one event that “causes” autism, genetic influences interact with numerous biological and developmental factors. In an individual person's case, it is generally impossible to point to a particular event during pregnancy or birth and say, “that is what caused it.”
A similar image of what the Stubbs Terrace hallway looked like in 1990.
The boy is standing next to the dining room door, while the girl is sitting on the stairs leading to the bathrooms and dormitories. The two children are walking towards the hallway leading to the locked reception door at the end. The lounge room was to the right, while the passage to the left led to the playroom, computer room and games room, which had a pool table and piano. Both were later removed when the games room became the meditation room.
Autism and ADHD
Autism also has a close relationship with Attention Deficit Hyperactivity Disorder, or ADHD. They are separate neurodevelopmental conditions but frequently occur together and share some genetic influences.
The combination can apparently produce contradictory behaviour. An autistic child may strongly need routine and predictability while ADHD creates a need for novelty and stimulation. A child may become intensely focused on one activity while being almost unable to concentrate on another. They may desperately want organisation while constantly losing things or forgetting what they are supposed to be doing.
For most of Stubbs Terrace's history, clinicians were not able to formally diagnose autism and ADHD together under later DSM rules. It was not until DSM-5 in 2013 that the restriction preventing the two diagnoses being made together was removed.
How many autistic children passed through Stubbs Terrace?
At present, there does not appear to be any published statistics showing how many children admitted to Stubbs Terrace were diagnosed with autism.
Autism was already recognised and specifically treated within WA Mental Health Services before Stubbs Terrace opened. The same psychiatrist, Dr W. E. Robinson, was closely associated with establishing both Stubbs Terrace Hospital and the Mildred Creak Centre for Autistic Children.
More importantly, I have since discovered that a surprisingly large proportion of the people I came into contact with through Stubbs, as well as some cases identified through the limited published research available, had already been diagnosed with autism, either before they entered the hospital or while they were there. I just didn't know it as a child.
What remains unknown is how representative those people were of the Stubbs Terrace population as a whole. Without admission registers or a diagnostic breakdown, it would be wrong to turn my personal experience into a percentage for the hospital.
However, what is clear is that autism was part of Stubbs Terrace's history. Autistic children were among those who passed through the hospital at a time when both the diagnosis and treatment of autism were changing considerably.
The unanswered question is not whether autistic children were there.
It is how many were there, why they were admitted, what diagnoses were recorded alongside autism and how their autistic behaviour was understood and treated once they were inside.
