539839
research-article2014
APAXXX10.1177/0003065114539839Panel ReportEffective Treatment Strategies for Autism
ja Pa
Elizabeth J. Levey
62/3
Effective Treatment Strategies for Autism During the First Five Years of Development
T
here is a gap between, on the one hand, psychoanalytic theory regarding treatment for autism that recognizes both relational and body-based treatment and, on the other, conventional psychoanalytic treatment. Recent psychoanalytically based empirical research data indicate that treatment strategies exist to address the ineffective and pathological coping strategies present in infants and children with autism spectrum disorders (ASDs). This panel, chaired by Stephen Seligman, used videotape clips of therapy sessions over the course of a multi-year treatment of a child beginning at ten months, as well as verbal presentation of case material by the treating psychoanalyst, Molly Romer Witten. Gilbert Foley, a psychoanalyst, and Gerard Costa, a developmental psychologist and infant mental health specialist, were discussants; together they laid out the principles of the change process and illustrated the complex issues present early in life for children who present with behavior on the autism spectrum. Seligman began by introducing the topic of the psychoanalytic theory of autism by reviewing past and current controversies. The problem with the “refrigerator mother” theory, which postulated that autism is an infant’s defensive response to a cold, rejecting mother, was that it defined the problem unidimensionally. The pendulum has since swung in the other direction, and a new unimensional error is currently favored: the attribution of primary causal influence to neurobiological deficits in the infant. The truth, Seligman said, involves the interaction of endowment and environment. This transactional perspective is well described in the work of
Panel held at the Winter Meeting of the American Psychoanalytic Association, New York, January 18, 2014. Panelists: Stephen Seligman (chair), Molly Romer Witten, Gilbert Foley, Gerard Costa. DOI: 10.1177/0003065114539839 Downloaded from apa.sagepub.com at Bobst Library, New York University on June 1, 2015
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George Engel, a leading proponent of the biopsychosocial theory of health and illness. Engel published a paper on the theory in 1977, and today, thirty-seven years later, it is widely accepted as an explanatory model for such medical conditions as asthma and migraines, as well as psychiatric conditions like depression and anxiety. However, the unfortunate legacy of the refrigerator mother theory has left many clinicians and researchers reluctant to view autism through this lens. Witten opened her talk with a quote from Frieda Fromm-Reichmann (1990): “Severe loneliness cannot ordinarily be endured more than temporarily without leading to psychotic development.” This aptly summarizes Witten’s theory of the development of autistic features in a ten-month-old boy brought to her for consultation. Witten reviewed for the group the threefold criterion suggested by Stanley Greenspan (2000) for the diagnosis of autism: the child must demonstrate simultaneous dysfunction in sensorimotor integration, communication, and interpersonal relating. While many autism researchers lump these characteristics together, psychoanalytic treatment offers the possibility of psychological integration and supports growth of an independent self (Tsakiris 2000). It does this, Witten suggested, by acknowledging the discrete and multiple meanings of behavior, rather than simply tracking observable behavior. Witten described the presence of all three domains of dysfunction in her patient. She theorized that the presence of low motor tone at birth limited his ability both to meet his physical needs and to communicate them to his parents. This in turn created a sense of isolation from his own body and from the physical world. Based on their own complex histories, the parents misinterpreted his cues. Witten’s theory of the case was as follows: (1) The insufficient motor tone observed from birth to seven months created within the baby a psychological isolation from his own bodily experience and hence delayed the development of affects and affective range. (2) This low motor tone and inadequate affective range allowed the organization of only muted facial expressions, such that the parents did not know that the baby’s sensory barrier was repeatedly breached; during these unaddressed breaches, he experienced dissociation. This recurrent dissociation, brought on by an unmet need for soothing, constituted experiences of loneliness. Perhaps most important, this recurring dissociation prevented the development and expansion of the capacity to engage bodily aggression, first in the service of basic physiological functions that
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guide developmental momentum, and then in providing the motivation for relating, as well as a capacity for communication. (3) The meaning the parents ascribed to their baby’s dissociative behavior prevented them from comprehending the meaning of his cues and hence his needs. The baby’s loneliness, combined with isolation from his own ongoing experience of muted or distorted affect, unmodulated by parental containment, led to autistic behaviors such as gaze aversion, a desire not to be touched, and aimlessness. An aimless searching in the environment precluded the organization of aggression in the service of learning to reach out, explore, and relate to others. “Baby B,” as Witten calls her patient, was ten months old when brought to her office for consultation. From birth, he had had difficulty latching on to feed, and at four months had met the criteria for failure to thrive. This led to referrals to a number of specialists, all of whom gave the family the general message that B was developing normally and that his low weight was due to his mother’s anxiety about feeding. At seven months they consulted a doula, who recommended trying a preemie nipple, which proved helpful. The parents already believed that their child had autism, based on input from family and friends with autistic children, and through these contacts they were referred to Witten. Immediately apparent were B’s difficulty feeding and his tendency to disengage and move about aimlessly; the mother’s anxiety and sense of rejection around feeding; and the father’s reluctance to engage spontaneously. In working with the family, Witten saw the mother once a week alone, mother and baby together twice a week, and all three together for a double session once a week. She also met periodically with the father alone. In addition to seeing Witten, B worked with a team that included a speech therapist, occupational therapists, and play therapists. Over the course of their work together, Witten learned about the meaning that being a parent held for B’s mother (M) and father (D). M was the oldest child born to a depressed mother and a father who was absorbed with his work. When she was five years old, her mother could not get out of bed, and M took on the role of mother to her younger siblings, a job at which, being a child herself, she was not fully competent. She held a firm belief that she was not a competent mother to her own child in a way that echoed that early experience. B’s feeding difficulties reinforced that belief. His falling asleep when M tried to feed him also evoked the way her own mother had taken to her bed, and she interpreted
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his falling asleep as a rejection of her and a confirmation of her incompetence. The father, D, was the youngest child in his family, separated by more than ten years from the rest of his siblings. By the time he turned ten, and his parents divorced, he had been the only child at home for a few years. His parents had not discussed with him their plan to divorce. One day he simply came home from school and was told by his mother that his father no longer lived with them and that the family now consisted of just the two of them. As he was the last child, he lived through his mother’s post-divorce depression, which lasted until he went to college. For many years, D wondered why his father had abandoned him and felt unlovable in a basic way. As an adult, he and his father started a company together, but their work relationship always seemed contentious. D’s father had died unexpectedly a year before D and M met. Together, D and Witten discovered a number of meanings this history may have infused into his relationship with his son. As André Green (1999) has said, “We carry within ourselves the totality of our past, which does not mean that we carry it as memories but as a set of organizers” (p. 69). In response to his feelings of rejection by his own father, D had become so defended against his desire for a playful father-son relationship that he simply could not access his capacity for play. During her talk, Witten showed four video clips meant to illustrate her experience in the room with this family and B’s development over the course of therapy. With the first clip, Witten showed how the family handled feeding. When B seemed hungry, M pulled out a bottle, at the sight of which the baby crawled across the floor to the couch where she was sitting. She carefully placed the bottle into his mouth, pointing it downward, allowing gravity to do much of the work. M’s experience had been that B seemed to stiffen when he was held, so she allowed him to feed in this way, not wanting to force him to be held to meet her own need for closeness. She was clearly disappointed with this arrangement, though, and commented that it seemed to be further evidence that she was not a good enough mother. It was clear to Witten that M was attaching meaning to B’s behavior that was rooted in the past and was not an accurate interpretation of B’s experience in the present. The parents were most bothered by B’s lack of eye contact and apparent aversion to being held. They believed this was motivating his preference to feed from the floor on all fours. When B
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stiffened when held, his mother, seeing this as confirmation of her assumption, retreated from pursuing further engagement, which her son seemed not to want; thus she avoided feelings of remembered rejection that were acutely painful to her. Witten had another theory. Given this difficulty feeding from birth, and taking the usefulness of the preemie nipple as a helpful clue, she believed that B’s low motor tone was a primary factor driving these downstream problems. She encouraged the mother to hold B and showed her how to wrap her arms around him in a way that was motorically containing and positioned them face to face. M became comfortable with this, and within a few sessions B began to explore her face with his eyes and hands. In the next clip, also from the second session, B had stuffed a twoinch piece of banana into his small mouth such that he could not breathe or swallow, or move the food around with his tongue. B moved aimlessly around the office, not seeking out his parents for help, and their worry was evident. Witten coached D to move slowly toward B and urge him to come sit on his lap and stop moving so he could organize his motor activity around eating the banana, which he could neither chew and swallow nor figure out how to spit out. Eventually, in his father’s lap, he was able to chew and swallow the banana. In the third clip, from the sixth session, as M and B were developing a comfortable feeding pattern, the low rumble of a truck driving by the office interrupted their connection. B’s attention shifted from eating to searching for the source of the frightening sound, and his hand moved away from his mother’s face. M’s smile faded as her face dropped, conveying her experience of rejection and isolation. B resumed sucking but with his gaze averted and without apparent interest in playing with M. Witten coached the mother to pull back gently on the bottle in order to capture B’s attention. She did so for a brief moment, and as the bottle was returned to him, B looked up at his mother and reconnected with her. Witten described B’s disengagement following the noise from the truck as a “dissociative state of goal-less drive reduction.” There was a discussion involving the audience about whether this episode was truly dissociation or was simply distraction. The question was raised as to the precise meaning of dissociation. Witten explained that she observed B stiffen and avert his gaze while continuing to suck, which she characterized as dissociation from the perspective of drive theory. B did not orient
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toward the noise but did shift attention away from his mother. He continued to feed but in a way that was relationally disengaged, as though he had shut down his affective contact with the external world in an attempt to mute the overwhelming auditory input he had just received. The final video clip showed B at thirty-three months engaged in pretend play with his parents. The session followed a meeting between Witten and D in which the father shared that B “feels lonely” when D is at work during the day. D had experienced B’s statement to that effect as manipulative. In the session with Witten, he was able to work through a series of associations to connect it to his own painful experience of losing his father when his parents divorced. Poignantly, he asked Witten, “Do you think it’s okay if I tell him I miss him too?” In the clip, B has brought his favorite toy truck, an “excavator,” into the session. He is playing the “Officer,” whose job it is to drive the excavator. M is “Dexter,” a worker who “goes off to build buildings.” D plays the “Fireman,” who “rescues people.” Dexter and the Fireman both want turns to drive the excavator. The Officer initially refuses them, but when they show disappointment, he relents. B then associates to the anger he felt at giving up control of the excavator, telling his father that he was mad at him for going to work that day. Then B tells D that he missed him. At this point the three of them begin to talk together about loneliness. This seems to overwhelm B, and he starts to clean up, as if the session were over. The conversation eventually turns back to loneliness. D tells B that he missed him too. B then collapses on the floor, flat on his back, losing all motor tone, in an illustration of infantile defenses described by Fraiberg (1982). Eventually returning to the play, B introduces an object called “the cheese.” Dexter and the Fireman have made the Officer angry by driving his excavator, so they are banished to the cheese, where loneliness serves as their punishment. In B’s articulation of loneliness as punishment, Witten was reminded of B’s disengagement as an infant when M did not respond to his cues or meet his needs. In the play, Dexter and Fireman had not responded to the Officer’s cues that he did not want to share the excavator and had persisted in their pleading. At home that night, after the session, B curled up with M for his bedtime bottle. M texted Witten that night: “Boy, it felt like this is what I have been waiting for since he was born.” In his discussion of Witten’s presentation, Foley spoke about the complex etiology of autism, with genetic vulnerabilities and caregiver
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factors interacting in continuous fashion to shape the child’s developmental trajectory. Using the term “psychogenic autism,” he made a distinction with respect to the degree of genetically based social impairment present in a particular case. He was careful to note that even in the presence of significant genetic loading for autism, the infant-caregiver dyad still plays a crucial role in the child’s social development, precisely because of the potential for it to be derailed by the child’s lack of social reinforcement by caregivers. In his work, Foley has found feeding to be particularly difficult for infants with sensorimotor impairment. He has observed that severely altered patterns of action and reaction, sucking and swallowing, muscle tone, and so forth in the baby can set in motion a cycle of severely compromised patterns of interaction contributing to arrested attachment in parents who are essentially competent and loving caregivers (Foley 1985). Foley considered Baby B’s to be a case of psychogenic autism for two reasons. First, his primary impairment appeared to be in the sensori motor domain. The developmental trajectory he began to follow once in treatment shows that neurobiologically he was capable of social relating. Second, the meaning to his parents of B’s failure to relate held clear and intense echoes of the past for both of them. B lacked the sensorimotor capacity to entice his parents. They interpreted the problem to be their deficit in enticing him, and they retreated, feeling rejected. As the case unfolded, it was evident that B and his parents shared an unconscious experience of the connection between loneliness and anger. Loneliness can be used to punish another for making one angry, and self-imposed loneliness (retreat) can be used to protect others from one’s angry feelings and aggressive impulses. Thus, B’s own annihilation anxiety had strong resonance for his parents. Foley further suggested that repair and containment are essential to the analytic work in this case. In the room with three individuals who had no internal framework to allow them to work with their aggression, Witten contained it for them until it began to be safe to explore it relationally with one another. Foley again raised the question of dissociation and whether the term can be applied in this case, as Witten did when the truck drove past her office and B disengaged from his mother. He argued that given B’s apparent hypersensitivity to external stimuli, his “shutting down and turning away” could be best understood as a freezing response, akin to “fight, flight, or feign death.” Foley went on to say, though, that an infant
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repeatedly forced to over-rely on shutting down as a coping mechanism may well be at higher risk for developing defensive patterns of withdrawal and dissociation (Foley 2006). Costa provided an overview of what is known about the neurobiology of autism. An understanding of the neurobiological processes at work strongly argues for thinking about and caring for patients from a multisensory, multidisciplinary perspective. A few of the key findings he discussed relate to hemispheric localization and the role of the limbic system. Right hemisphere structures appear active earlier than left hemisphere structures. The former are the parts of the brain that recognize affect and tone rather than the content of what is said. Shared affective and neurological states (“we” circuits) are intrinsic to the infant’s psychological development in a relational context (Siegel 2010). Limbic development begins early and occurs in a relational context (Schore 2011). The limbic system plays an essential role in emotion processing and memory, implying a link between emotional memories and the processing of current emotion. The limbic system is also involved in shaping neural circuitry. “When a baby senses safety, warmth, and security,” Costa explained, “the limbic system gets ‘wired’ to attend, remain calm and engaged, and to store memories about the body, about the world and the people who are there for them.” However, if the infant is exposed to a stressful environment, the limbic system is activated in a way that has negative effects on development. High levels of early stress perceived by the amygdala activate the hypothalamic-pituitary axis, releasing corticosteroids and impairing prefrontal cortical development. All this is to say that early intervention in children with ASD vulnerabilities is all the more compelling when considering the effects of early caregiver interactions not only on the mind but also on the brain. Costa referenced a recent study, by a group of researchers at Vanderbilt, which found that children with ASDs process visual and auditory input separately and have difficulty processing simultaneous input into different sensory modalities (Stevenson et al. 2014). If B has this ASD feature, it might have contributed to his difficulty maintaining eye contact with his mother when he heard the noise of the truck. Costa observed that Baby B came to the relational process with constitutional neurobiological compromises and that both parents arrived with historical, intrapsychic, emotional, and behavioral dynamics that compromised their capacity for attuned, responsive, and co-regulated care of their child.
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In children with such constitutional vulnerabilities, both the baby’s signals and the caregiver’s responses are not well matched and synchronized, and an alteration occurs in the unfolding developmental trajectory of child and caregivers. This is compounded by parental projections and interpretations of the baby’s miscues. A rich discussion followed the panelists’ presentations, with a number of thought-provoking questions from the audience. People wondered whether B truly had an ASD. Without Witten’s work with this family, it is impossible to say whether B would have followed an autistic developmental path. Seligman raised the question whether there is a distinction between biological and psychological autism, as Foley had suggested. There was general agreement that every case is impacted by both biological and psychological factors, to varying degrees. Costa offered that the diagnosis describes a cluster of symptoms that is not biologically meaningful, and as we learn more about the brain, it is becoming obsolete. Witten suggested that autism is a process rather than a state of diseased functioning. Witten’s thoughtful, nuanced case presentation raised questions that are essential to our understanding of autism and hold significant treatment implications. Like all psychiatric diagnoses, autism is defined by the presence of certain symptoms and not by a specific pathophysiological process. It is a final common (though quite heterogeneous) pathway for what is likely a wide variety of primary etiologies. The fact that a child who has displayed autistic behavior at ten months can fall in the normal developmental range at age four highlights the importance of taking the time to get to know a child and a family well in order to develop an understanding of all the factors at play, to intervene in multiple domains, and to help the family make meaning of its experience. References
Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science 196(4286):129–136. Foley, G.M. (1985). Emotional development of children with handicaps. Journal of Children in Contemporary Society 17:57–73. Foley, G.M. (2006). Self and social-emotional development in infancy: A descriptive synthesis. In Mental Health in Early Intervention: Achieving Unity in Principles and Practice, ed. G.M. Foley & J.D. Hochman. Baltimore: Paul H. Brookes, pp. 139–173.
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Fraiberg, S. (1982). Pathological defenses in infancy. Psychoanalytic Quarterly 51:612–635. Fromm-Reichmann, F. (1990). Loneliness. Contemporary Psychoanalysis 26:305–329. Green, A. (1999). The Fabric of Affect in the Psychoanalytic Discourse. London: Routledge. Greenspan, S.I. (2000). Children with autistic spectrum disorders: Individual differences, affect, interaction, and outcomes. Psychoanalytic Inquiry 20:675–703. Schore, A.N. (2011). The right brain implicit self lies at the core of psychoanalysis. Psychoanalytic Dialogues 21:75–100. Siegel, D.J. (2010). Mindsight: The New Science of Personal Transformation. New York: Bantam Books. Stevenson, R.A., Siemann, J.K., Schneider, B.C., Eberly, H.E., Woynaroski, T.G., Camarata, S.M., & Wallace, M.T. (2014). Multisensory temporal integration in autism spectrum disorders. Journal of Neuroscience 34:691–697. Tsakiris, E.A. (2000). Evaluating effective interventions for children with autism and related disorders: Widening the view and changing the perspective. In Clinical Practice Guidelines: Redefining the Standards of Care for Infants, Children, and Families with Special Needs, ed. ICDL Clinical Practice Guidelines Workgroup. Bethesda, MD: ICDL, pp. 725–820. 32 Fruit Street Boston, MA 02114 E-mail: [email protected]
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research-article2014
APAXXX10.1177/0003065114539839Panel ReportEffective Treatment Strategies for Autism
ja Pa
Elizabeth J. Levey
62/3
Effective Treatment Strategies for Autism During the First Five Years of Development
T
here is a gap between, on the one hand, psychoanalytic theory regarding treatment for autism that recognizes both relational and body-based treatment and, on the other, conventional psychoanalytic treatment. Recent psychoanalytically based empirical research data indicate that treatment strategies exist to address the ineffective and pathological coping strategies present in infants and children with autism spectrum disorders (ASDs). This panel, chaired by Stephen Seligman, used videotape clips of therapy sessions over the course of a multi-year treatment of a child beginning at ten months, as well as verbal presentation of case material by the treating psychoanalyst, Molly Romer Witten. Gilbert Foley, a psychoanalyst, and Gerard Costa, a developmental psychologist and infant mental health specialist, were discussants; together they laid out the principles of the change process and illustrated the complex issues present early in life for children who present with behavior on the autism spectrum. Seligman began by introducing the topic of the psychoanalytic theory of autism by reviewing past and current controversies. The problem with the “refrigerator mother” theory, which postulated that autism is an infant’s defensive response to a cold, rejecting mother, was that it defined the problem unidimensionally. The pendulum has since swung in the other direction, and a new unimensional error is currently favored: the attribution of primary causal influence to neurobiological deficits in the infant. The truth, Seligman said, involves the interaction of endowment and environment. This transactional perspective is well described in the work of
Panel held at the Winter Meeting of the American Psychoanalytic Association, New York, January 18, 2014. Panelists: Stephen Seligman (chair), Molly Romer Witten, Gilbert Foley, Gerard Costa. DOI: 10.1177/0003065114539839 Downloaded from apa.sagepub.com at Bobst Library, New York University on June 1, 2015
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Panel Report
George Engel, a leading proponent of the biopsychosocial theory of health and illness. Engel published a paper on the theory in 1977, and today, thirty-seven years later, it is widely accepted as an explanatory model for such medical conditions as asthma and migraines, as well as psychiatric conditions like depression and anxiety. However, the unfortunate legacy of the refrigerator mother theory has left many clinicians and researchers reluctant to view autism through this lens. Witten opened her talk with a quote from Frieda Fromm-Reichmann (1990): “Severe loneliness cannot ordinarily be endured more than temporarily without leading to psychotic development.” This aptly summarizes Witten’s theory of the development of autistic features in a ten-month-old boy brought to her for consultation. Witten reviewed for the group the threefold criterion suggested by Stanley Greenspan (2000) for the diagnosis of autism: the child must demonstrate simultaneous dysfunction in sensorimotor integration, communication, and interpersonal relating. While many autism researchers lump these characteristics together, psychoanalytic treatment offers the possibility of psychological integration and supports growth of an independent self (Tsakiris 2000). It does this, Witten suggested, by acknowledging the discrete and multiple meanings of behavior, rather than simply tracking observable behavior. Witten described the presence of all three domains of dysfunction in her patient. She theorized that the presence of low motor tone at birth limited his ability both to meet his physical needs and to communicate them to his parents. This in turn created a sense of isolation from his own body and from the physical world. Based on their own complex histories, the parents misinterpreted his cues. Witten’s theory of the case was as follows: (1) The insufficient motor tone observed from birth to seven months created within the baby a psychological isolation from his own bodily experience and hence delayed the development of affects and affective range. (2) This low motor tone and inadequate affective range allowed the organization of only muted facial expressions, such that the parents did not know that the baby’s sensory barrier was repeatedly breached; during these unaddressed breaches, he experienced dissociation. This recurrent dissociation, brought on by an unmet need for soothing, constituted experiences of loneliness. Perhaps most important, this recurring dissociation prevented the development and expansion of the capacity to engage bodily aggression, first in the service of basic physiological functions that
476
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guide developmental momentum, and then in providing the motivation for relating, as well as a capacity for communication. (3) The meaning the parents ascribed to their baby’s dissociative behavior prevented them from comprehending the meaning of his cues and hence his needs. The baby’s loneliness, combined with isolation from his own ongoing experience of muted or distorted affect, unmodulated by parental containment, led to autistic behaviors such as gaze aversion, a desire not to be touched, and aimlessness. An aimless searching in the environment precluded the organization of aggression in the service of learning to reach out, explore, and relate to others. “Baby B,” as Witten calls her patient, was ten months old when brought to her office for consultation. From birth, he had had difficulty latching on to feed, and at four months had met the criteria for failure to thrive. This led to referrals to a number of specialists, all of whom gave the family the general message that B was developing normally and that his low weight was due to his mother’s anxiety about feeding. At seven months they consulted a doula, who recommended trying a preemie nipple, which proved helpful. The parents already believed that their child had autism, based on input from family and friends with autistic children, and through these contacts they were referred to Witten. Immediately apparent were B’s difficulty feeding and his tendency to disengage and move about aimlessly; the mother’s anxiety and sense of rejection around feeding; and the father’s reluctance to engage spontaneously. In working with the family, Witten saw the mother once a week alone, mother and baby together twice a week, and all three together for a double session once a week. She also met periodically with the father alone. In addition to seeing Witten, B worked with a team that included a speech therapist, occupational therapists, and play therapists. Over the course of their work together, Witten learned about the meaning that being a parent held for B’s mother (M) and father (D). M was the oldest child born to a depressed mother and a father who was absorbed with his work. When she was five years old, her mother could not get out of bed, and M took on the role of mother to her younger siblings, a job at which, being a child herself, she was not fully competent. She held a firm belief that she was not a competent mother to her own child in a way that echoed that early experience. B’s feeding difficulties reinforced that belief. His falling asleep when M tried to feed him also evoked the way her own mother had taken to her bed, and she interpreted
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his falling asleep as a rejection of her and a confirmation of her incompetence. The father, D, was the youngest child in his family, separated by more than ten years from the rest of his siblings. By the time he turned ten, and his parents divorced, he had been the only child at home for a few years. His parents had not discussed with him their plan to divorce. One day he simply came home from school and was told by his mother that his father no longer lived with them and that the family now consisted of just the two of them. As he was the last child, he lived through his mother’s post-divorce depression, which lasted until he went to college. For many years, D wondered why his father had abandoned him and felt unlovable in a basic way. As an adult, he and his father started a company together, but their work relationship always seemed contentious. D’s father had died unexpectedly a year before D and M met. Together, D and Witten discovered a number of meanings this history may have infused into his relationship with his son. As André Green (1999) has said, “We carry within ourselves the totality of our past, which does not mean that we carry it as memories but as a set of organizers” (p. 69). In response to his feelings of rejection by his own father, D had become so defended against his desire for a playful father-son relationship that he simply could not access his capacity for play. During her talk, Witten showed four video clips meant to illustrate her experience in the room with this family and B’s development over the course of therapy. With the first clip, Witten showed how the family handled feeding. When B seemed hungry, M pulled out a bottle, at the sight of which the baby crawled across the floor to the couch where she was sitting. She carefully placed the bottle into his mouth, pointing it downward, allowing gravity to do much of the work. M’s experience had been that B seemed to stiffen when he was held, so she allowed him to feed in this way, not wanting to force him to be held to meet her own need for closeness. She was clearly disappointed with this arrangement, though, and commented that it seemed to be further evidence that she was not a good enough mother. It was clear to Witten that M was attaching meaning to B’s behavior that was rooted in the past and was not an accurate interpretation of B’s experience in the present. The parents were most bothered by B’s lack of eye contact and apparent aversion to being held. They believed this was motivating his preference to feed from the floor on all fours. When B
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stiffened when held, his mother, seeing this as confirmation of her assumption, retreated from pursuing further engagement, which her son seemed not to want; thus she avoided feelings of remembered rejection that were acutely painful to her. Witten had another theory. Given this difficulty feeding from birth, and taking the usefulness of the preemie nipple as a helpful clue, she believed that B’s low motor tone was a primary factor driving these downstream problems. She encouraged the mother to hold B and showed her how to wrap her arms around him in a way that was motorically containing and positioned them face to face. M became comfortable with this, and within a few sessions B began to explore her face with his eyes and hands. In the next clip, also from the second session, B had stuffed a twoinch piece of banana into his small mouth such that he could not breathe or swallow, or move the food around with his tongue. B moved aimlessly around the office, not seeking out his parents for help, and their worry was evident. Witten coached D to move slowly toward B and urge him to come sit on his lap and stop moving so he could organize his motor activity around eating the banana, which he could neither chew and swallow nor figure out how to spit out. Eventually, in his father’s lap, he was able to chew and swallow the banana. In the third clip, from the sixth session, as M and B were developing a comfortable feeding pattern, the low rumble of a truck driving by the office interrupted their connection. B’s attention shifted from eating to searching for the source of the frightening sound, and his hand moved away from his mother’s face. M’s smile faded as her face dropped, conveying her experience of rejection and isolation. B resumed sucking but with his gaze averted and without apparent interest in playing with M. Witten coached the mother to pull back gently on the bottle in order to capture B’s attention. She did so for a brief moment, and as the bottle was returned to him, B looked up at his mother and reconnected with her. Witten described B’s disengagement following the noise from the truck as a “dissociative state of goal-less drive reduction.” There was a discussion involving the audience about whether this episode was truly dissociation or was simply distraction. The question was raised as to the precise meaning of dissociation. Witten explained that she observed B stiffen and avert his gaze while continuing to suck, which she characterized as dissociation from the perspective of drive theory. B did not orient
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toward the noise but did shift attention away from his mother. He continued to feed but in a way that was relationally disengaged, as though he had shut down his affective contact with the external world in an attempt to mute the overwhelming auditory input he had just received. The final video clip showed B at thirty-three months engaged in pretend play with his parents. The session followed a meeting between Witten and D in which the father shared that B “feels lonely” when D is at work during the day. D had experienced B’s statement to that effect as manipulative. In the session with Witten, he was able to work through a series of associations to connect it to his own painful experience of losing his father when his parents divorced. Poignantly, he asked Witten, “Do you think it’s okay if I tell him I miss him too?” In the clip, B has brought his favorite toy truck, an “excavator,” into the session. He is playing the “Officer,” whose job it is to drive the excavator. M is “Dexter,” a worker who “goes off to build buildings.” D plays the “Fireman,” who “rescues people.” Dexter and the Fireman both want turns to drive the excavator. The Officer initially refuses them, but when they show disappointment, he relents. B then associates to the anger he felt at giving up control of the excavator, telling his father that he was mad at him for going to work that day. Then B tells D that he missed him. At this point the three of them begin to talk together about loneliness. This seems to overwhelm B, and he starts to clean up, as if the session were over. The conversation eventually turns back to loneliness. D tells B that he missed him too. B then collapses on the floor, flat on his back, losing all motor tone, in an illustration of infantile defenses described by Fraiberg (1982). Eventually returning to the play, B introduces an object called “the cheese.” Dexter and the Fireman have made the Officer angry by driving his excavator, so they are banished to the cheese, where loneliness serves as their punishment. In B’s articulation of loneliness as punishment, Witten was reminded of B’s disengagement as an infant when M did not respond to his cues or meet his needs. In the play, Dexter and Fireman had not responded to the Officer’s cues that he did not want to share the excavator and had persisted in their pleading. At home that night, after the session, B curled up with M for his bedtime bottle. M texted Witten that night: “Boy, it felt like this is what I have been waiting for since he was born.” In his discussion of Witten’s presentation, Foley spoke about the complex etiology of autism, with genetic vulnerabilities and caregiver
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factors interacting in continuous fashion to shape the child’s developmental trajectory. Using the term “psychogenic autism,” he made a distinction with respect to the degree of genetically based social impairment present in a particular case. He was careful to note that even in the presence of significant genetic loading for autism, the infant-caregiver dyad still plays a crucial role in the child’s social development, precisely because of the potential for it to be derailed by the child’s lack of social reinforcement by caregivers. In his work, Foley has found feeding to be particularly difficult for infants with sensorimotor impairment. He has observed that severely altered patterns of action and reaction, sucking and swallowing, muscle tone, and so forth in the baby can set in motion a cycle of severely compromised patterns of interaction contributing to arrested attachment in parents who are essentially competent and loving caregivers (Foley 1985). Foley considered Baby B’s to be a case of psychogenic autism for two reasons. First, his primary impairment appeared to be in the sensori motor domain. The developmental trajectory he began to follow once in treatment shows that neurobiologically he was capable of social relating. Second, the meaning to his parents of B’s failure to relate held clear and intense echoes of the past for both of them. B lacked the sensorimotor capacity to entice his parents. They interpreted the problem to be their deficit in enticing him, and they retreated, feeling rejected. As the case unfolded, it was evident that B and his parents shared an unconscious experience of the connection between loneliness and anger. Loneliness can be used to punish another for making one angry, and self-imposed loneliness (retreat) can be used to protect others from one’s angry feelings and aggressive impulses. Thus, B’s own annihilation anxiety had strong resonance for his parents. Foley further suggested that repair and containment are essential to the analytic work in this case. In the room with three individuals who had no internal framework to allow them to work with their aggression, Witten contained it for them until it began to be safe to explore it relationally with one another. Foley again raised the question of dissociation and whether the term can be applied in this case, as Witten did when the truck drove past her office and B disengaged from his mother. He argued that given B’s apparent hypersensitivity to external stimuli, his “shutting down and turning away” could be best understood as a freezing response, akin to “fight, flight, or feign death.” Foley went on to say, though, that an infant
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repeatedly forced to over-rely on shutting down as a coping mechanism may well be at higher risk for developing defensive patterns of withdrawal and dissociation (Foley 2006). Costa provided an overview of what is known about the neurobiology of autism. An understanding of the neurobiological processes at work strongly argues for thinking about and caring for patients from a multisensory, multidisciplinary perspective. A few of the key findings he discussed relate to hemispheric localization and the role of the limbic system. Right hemisphere structures appear active earlier than left hemisphere structures. The former are the parts of the brain that recognize affect and tone rather than the content of what is said. Shared affective and neurological states (“we” circuits) are intrinsic to the infant’s psychological development in a relational context (Siegel 2010). Limbic development begins early and occurs in a relational context (Schore 2011). The limbic system plays an essential role in emotion processing and memory, implying a link between emotional memories and the processing of current emotion. The limbic system is also involved in shaping neural circuitry. “When a baby senses safety, warmth, and security,” Costa explained, “the limbic system gets ‘wired’ to attend, remain calm and engaged, and to store memories about the body, about the world and the people who are there for them.” However, if the infant is exposed to a stressful environment, the limbic system is activated in a way that has negative effects on development. High levels of early stress perceived by the amygdala activate the hypothalamic-pituitary axis, releasing corticosteroids and impairing prefrontal cortical development. All this is to say that early intervention in children with ASD vulnerabilities is all the more compelling when considering the effects of early caregiver interactions not only on the mind but also on the brain. Costa referenced a recent study, by a group of researchers at Vanderbilt, which found that children with ASDs process visual and auditory input separately and have difficulty processing simultaneous input into different sensory modalities (Stevenson et al. 2014). If B has this ASD feature, it might have contributed to his difficulty maintaining eye contact with his mother when he heard the noise of the truck. Costa observed that Baby B came to the relational process with constitutional neurobiological compromises and that both parents arrived with historical, intrapsychic, emotional, and behavioral dynamics that compromised their capacity for attuned, responsive, and co-regulated care of their child.
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In children with such constitutional vulnerabilities, both the baby’s signals and the caregiver’s responses are not well matched and synchronized, and an alteration occurs in the unfolding developmental trajectory of child and caregivers. This is compounded by parental projections and interpretations of the baby’s miscues. A rich discussion followed the panelists’ presentations, with a number of thought-provoking questions from the audience. People wondered whether B truly had an ASD. Without Witten’s work with this family, it is impossible to say whether B would have followed an autistic developmental path. Seligman raised the question whether there is a distinction between biological and psychological autism, as Foley had suggested. There was general agreement that every case is impacted by both biological and psychological factors, to varying degrees. Costa offered that the diagnosis describes a cluster of symptoms that is not biologically meaningful, and as we learn more about the brain, it is becoming obsolete. Witten suggested that autism is a process rather than a state of diseased functioning. Witten’s thoughtful, nuanced case presentation raised questions that are essential to our understanding of autism and hold significant treatment implications. Like all psychiatric diagnoses, autism is defined by the presence of certain symptoms and not by a specific pathophysiological process. It is a final common (though quite heterogeneous) pathway for what is likely a wide variety of primary etiologies. The fact that a child who has displayed autistic behavior at ten months can fall in the normal developmental range at age four highlights the importance of taking the time to get to know a child and a family well in order to develop an understanding of all the factors at play, to intervene in multiple domains, and to help the family make meaning of its experience. References
Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science 196(4286):129–136. Foley, G.M. (1985). Emotional development of children with handicaps. Journal of Children in Contemporary Society 17:57–73. Foley, G.M. (2006). Self and social-emotional development in infancy: A descriptive synthesis. In Mental Health in Early Intervention: Achieving Unity in Principles and Practice, ed. G.M. Foley & J.D. Hochman. Baltimore: Paul H. Brookes, pp. 139–173.
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Fraiberg, S. (1982). Pathological defenses in infancy. Psychoanalytic Quarterly 51:612–635. Fromm-Reichmann, F. (1990). Loneliness. Contemporary Psychoanalysis 26:305–329. Green, A. (1999). The Fabric of Affect in the Psychoanalytic Discourse. London: Routledge. Greenspan, S.I. (2000). Children with autistic spectrum disorders: Individual differences, affect, interaction, and outcomes. Psychoanalytic Inquiry 20:675–703. Schore, A.N. (2011). The right brain implicit self lies at the core of psychoanalysis. Psychoanalytic Dialogues 21:75–100. Siegel, D.J. (2010). Mindsight: The New Science of Personal Transformation. New York: Bantam Books. Stevenson, R.A., Siemann, J.K., Schneider, B.C., Eberly, H.E., Woynaroski, T.G., Camarata, S.M., & Wallace, M.T. (2014). Multisensory temporal integration in autism spectrum disorders. Journal of Neuroscience 34:691–697. Tsakiris, E.A. (2000). Evaluating effective interventions for children with autism and related disorders: Widening the view and changing the perspective. In Clinical Practice Guidelines: Redefining the Standards of Care for Infants, Children, and Families with Special Needs, ed. ICDL Clinical Practice Guidelines Workgroup. Bethesda, MD: ICDL, pp. 725–820. 32 Fruit Street Boston, MA 02114 E-mail: [email protected]
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