A treatment for autistic children with psychiatric problems that has never been tested is routinely used in France. Some psychiatrists say the technique has produced therapeutic results. But critics say that it is cruel, unproven, and potentially dangerous. Laura Spinney investigates.

In France, autistic children who have psychiatric problems routinely undergo a treatment that has never been tested in a clinical trial and that many parents regard as cruel. Psychiatrists who use the technique claim that it produces positive results, but critics argue that it shows just how far France has fallen out of step with the international medical community in its understanding of the condition.

The therapy, called packing, involves wrapping a child tightly in wet sheets that have been placed in the refrigerator for up to an hour. When children are encased in this damp cocoon—with only their head left free—psychiatrically trained staff talk to them about their feelings. Typically, the treatment is repeated several times a week, and depending on the results and the severity of the child's condition, it can continue for months or even years.

The man who pioneered packing for children, Pierre Delion, is head of the child and adolescent psychiatry unit at Lille Regional University Hospital in northern France. He says that it reinforces childrens' consciousness of their bodily limits, which in some psychiatric conditions becomes fragmented. He recommends that the technique be used for three types of patient: severely autistic children who self-harm; psychotic children; and, more rarely, children with anorexia. Referring to the first category, he has written, “In our experience of packing, self-harming behaviour very often disappears”.

Forms of wrapping or envelopment—for example, in mud or clay—have been used therapeutically for centuries. The idea of using it to calm violent patients was conceived in Germany in the 19th century, and packing was routinely applied at Chestnut Lodge—an asylum in Rockville, Maryland—in the 1950s.

A decade later, American psychiatrist Michael Woodbury brought it to France, where it was embraced by the influential psychoanalytic movement, whose founder was Sigmund Freud. Psychoanalysts found that Woodbury's philosophy dovetailed with ideas they had about children's development. One psychoanalytic theory holds, for example, that packing can help children to dismantle the defensive behaviours they developed at an early age, to protect themselves from a dysfunctional relationship with their mother.

In 1996, the French National Consultative Ethics Committee for Health and Life Sciences published a report stating that there was no evidence to substantiate psycho-analytic models of autism, nor that therapies based on this model were effective. The authors were also concerned that, in France, childhood autism was classified as an infantile psychosis, whereas the term psychosis had been dropped from international and US descriptions. In both WHO's International Classification of Diseases and the US Diagnostic and Statistical Manual of Mental Disorders, autism is now described as a pervasive developmental disorder.

David Cohen heads the child and psychiatry service at the Pitié-Salpêtrière Hospital in Paris, where packing is used alongside specialised education and medication for some severely autistic and schizophrenic children. He regards it as a valuable adjunct therapy, and he says there is no need to evoke psychoanalytic concepts to account for the “dramatic improvements” he sees in children who have received it. Rather, he says, packing should be viewed as a form of “bodily mediation”, like massage, which relaxes the child while he receives psychotherapy. He admits, however, that using it simultaneously with other treatments makes it impossible to judge whether any observed improvements can be credited to the packing.

According to Delion, current interpretations of the mechanism of action of packing are academic. “For me, it combines the body and the image of the body—the two are entirely complementary”, he says. “However, I do not think that debate is useful, which is why we would now like to move it onto a more scientific plane.”

Packing is used as an adjunct therapy at the Pitié-Salpêtrière Hospital in Paris

In June, a small clinical trial got underway in Lille—the first to try to hone in on the therapeutic effects of packing. In 120 children, the investigators will compare one group wrapped in dry sheets with one wrapped in wet, cold ones, on a battery of clinical, electrophysiological, and other measures. Later, Delion hopes to identify a neurophysiological mechanism underlying the technique, which he speculates may involve temperature sensors in the brain.

Meanwhile, the technique continues to be practised in French clinics, often under the supervision of psychomotriciens—a type of occupational therapist. Delion, who has been training professionals for 25 years, thinks that there must be several hundred teams using it across the country. A day-case hospital in Bordeaux that used packing was the focus of a short documentary aired on French TV in April, which provoked outrage from organisations representing parents of autistic children. The biggest of these—Autism France—officially complained to the TV channel and to the French health minister.

“If you hit someone over the head with a hammer, obviously when you stop they will be very happy”, says Autism France's president, Mireille Lemahieu. “But it is not because they are made happy that hammering them over the head is a good thing.” She points to potential negative effects of the treatment, such as seizures and heart attacks, which could result from the thermal shock of being swaddled in icy sheets.

She also points out that children who cannot speak—which accounts for most of the recipients of packing—cannot withhold their consent for a procedure that they do not enjoy. For Delion, this is not an issue, “If a child is in a road accident”, he says, “you do not wait to ask his consent to give him a blood transfusion”. He believes it a case of doing what is best for the child in a situation in which the child cannot help himself, and he emphasises that parents' consent is always sought. Usually, once the parents have agreed, a psychiatrist explains to the child what is going to happen, sometimes with the help of a doll. If the idea seems not to upset the child too much, the packing goes ahead. A child who declines to enter the pack is never forced.

Olivier Bousquet worked as a psychiatric nurse for 9 years until he gave up to care for his autistic son. As a baby, he says, his son could not bear to wear clothes or be caressed. However, like the autistic author and scientist Temple Grandin, he enjoyed the firm application of pressure to his skin. Grandin invented the “hug machine” to give her the kind of pressure she liked, and both Cohen and Delion cite her as evidence that packing is pleasant for autistic patients. The difference, says Bousqet, is that Grandin could choose.

“It is very difficult to imagine my son wrapped in sheets, without being able to make a movement”, he says. “He would be distressed but he would not be able to express his distress.” Children often adopt the point of view that adults expect of them, he says. Above all, says Bousquet, state money (and health professionals' time) spent on packing would be better spent on established methods for teaching autistic children to communicate.

“It is a kind of aggression against somebody who cannot respond or defend themselves”, commented one shocked French psychiatrist, who preferred to remain nameless, on learning that the “old-fashioned” technique was still practised in France. She said that parents could be placed in a difficult position, because demand for places for autistic children at day hospitals or therapy centres often outstrips supply. “Whether or not it is true, they may be afraid that by saying no, and opposing the doctor's recommendations, they will jeopardise their child's place”, she says.

Patricia Howlin, professor of clinical child psychology at the Institute of Psychiatry, King's College London, who specialises in autism, had never heard of packing, which does not seem to be practised in the UK. However, Delion recently gave a course on the technique at the Tavistock Clinic in London, which is part of the UK's National Health Service. Maria Rhode, a psychotherapist at the clinic, points out that there are currently no effective treatments for autism, and that caring for such children presents a major, long-term challenge to health services.

“It is the case for an awful lot of interventions for children that the evidence base leaves a lot to be desired”, says Rhode. “What you are coming up against here is the very difficult interface between clinical judgment and evidence base.” Lack of proof of efficacy is not the same as lack of efficacy, she adds, and although she has concerns about the risk of adverse effects with packing, she believes that the benefits that Delion reports warrant investigation. Along with many others, she will be watching the clinical trial with interest.