Thursday, April 23, 2009

Making Sense of Autistic Behaviors

Flapping arms and hands, inability to use eye contact, lack of speech, the use of echolalia, inability to discern danger, inability to do anything on one’s own, head banging, running, failure to respond to one’s name and the ability to seemingly speak only about a narrow range of topics – are all commonly seen behaviors of individuals with an Autism Spectrum Disorder (ASD). These behaviors can be scary and most certainly difficult to live with and manage. To extinguish or to ‘get rid’ of these behaviors seems to be the way that most want to manage these unwanted ‘traits’. I would like to present another perspective of how one might want to view ‘autistic behaviors’. As I mentioned in previous blogs, I believe that the autistic child has not benefited from a completed attachment with a caregiver and thus the child is left in a waiting state for an attachment to occur. Each child will cope differently to the circumstance of having an “Incomplete Attachment” and thus will have different behaviors as compared to another child. Remember, that each child will also have varying ability to use one’s self in relationship to another. I have called this self-agency. Some children will be more conscious of themselves and thus have more access to use him or herself in relationship to others. Thus we have a continuum of ability, which is typically known as the functioning level of the individual on the spectrum (low functioning, high functioning and Aspergers). This state is confusing and scary for the child and for those working with the child.

It might be helpful to view these behaviors as ‘coping’ and state of existence’ behaviors that need to be understood and validated, but not extinguished. Some of the behaviors are ‘coping’ behaviors because they (the behaviors) are the only means the child has to communicate their frustration with their state of existence. Other behaviors can be called ‘state of existence’ behaviors because they literally communicate the psychological state of the child. It is my belief that every human being needs to communicate. The autistic child does not have access to use himself in relationship to another (lack of self-agency) so the only means of communication is nonverbal. The child does not have self-agency because he has dissociated emotions that he cannot access. He has dissociated emotions because he has not had a completed attachment with a caregiver. I like to think of the autistic individual as doing the best he/she can by communicating their state of existence through the behaviors they do use. It is the job of the caregiver/therapist to help the child by demonstrating that they do understand what the child is communicating through these behaviors. By letting the children know you understand, they feel validated and then the attachment process can once again be mobilized. Unfortunately, this process of developing an attachment with a person with autism can be very time consuming. Why it is so time consuming will be a discussion on another blog.

An example of how one works with a child from this perspective may be helpful. I was observing a three-year-old autistic boy. Up to that point, he had never played with any toy appropriately. I noticed he was picking his lips. I said “you are telling me something about talking by picking your lips”. He immediately looked at me and began to play appropriately with a toy for the first time. I believe that what happened here was 1) I did not try to extinguish his behavior, 2) I validated something inside of him, 3) he felt recognized, and 4) that allowed him to play.

Now it is time to demystify autistic behaviors. Based on an “Incomplete Attachment” the following categories seem to be appropriate: 1) lack of self-agency, 2) dissociation, 3) unconsciousness, 4) lack of social interaction/inhibition, 5) inability to communicate, and 6) coping techniques. These categories are a work in progress, and may change as I refine my thinking on this subject.

It might be helpful to describe how to make sense of the classification system I have devised. It is only meant to classify for understanding why and what is going on within the autistic individual. For example, echolalia is an example of a lack of self-agency. The child in this case, has no ability to use himself and thus all that is left to the child is to repeat back what they heard the other say. The child who is unable to name a toy is also without the ability to use himself. Thus these behaviors are classified under lack of self-agency.

When a child has a reduced sense of pain, he can be said to be in a dissociated state. The state that he has access to does not allow him to feel. An avoidance of eye contact can be recognized as an unconscious behavior. The unconscious only speaks nonverbally (dreams, nonverbal gestures). Avoidance of eye contact is not something the child does purposefully, but instead can be seen as one aspect of a child who is unconscious. As he becomes more conscious, his eye contact and ability to express himself will change. Finally most autistic children lack the ability to respond to others. Through the lens of an “Incomplete Attachment” one would say the children are unconscious, dissociated and thus lack the ability to use themselves in relationship to others. It is not that these children do not want a relationship, but instead their developmental ability to have a relationship has been delayed.

These brief explanations are meant to give you the idea that all the behaviors of an autistic person can be understood. We just need to be patient and creative in understanding and using this understanding in our work with this population.

1. Lack of Self-Agency
· Echolalia
· Provoked to do the bidding of others
· Fear of not being able to do anything on one’s own – speak, get a toy, name a toy, play with a toy, etc.

2. Dissociation
· Reduced sense of pain
· No sense of danger and need for safety
· Appear to be in their own world
· Exceptional savant skills
· Concrete thinking, and literalness
· Inability to generalize learning – learning social skills, modeling how to have a conversation, does not transfer or generalize to new environments. The child may be able to think through complex math problems but they cannot think through social interactions.
· Can’t shift thinking

3. Unconsciousness
· Avoid eye contact
· Little or no sense of the impact of her behavior on others (such as, bursting out the door, walking with his back fastened adhesively to the wall, walking behind the other person, literally walks over others, touching others inappropriately)
· Head banging or biting one’s self (unconscious nonverbal communication)
· Self-injurious behavior

4. Lack of Social Interaction/Inhibition
· Unresponsive to people
· May develop normally and then appear to withdraw and become indifferent to social engagement
· Pain when touched
· Resist cuddling or being hugged
· Absence or impairment of imaginative or social play
· Inability to initiate or sustain conversations
· Lack of a capacity to attribute mental states to others and to implicitly take account of the fact that different people have different thoughts (Theory of Mind)

5. Inability to Communicate
· Fail to respond to their name
· Either no language or stereotyped, repetitive, or unusual use of language – may speak in a sing-song manner
· May speak about a narrow range of topics
· Confusion in the use of pronouns, refer to self by name or use the third person ‘you’, instead of ‘I’ or ‘me’
· Pointing to indicate interest
· Inability to initiate or sustain conversations
· Obsession with details
· Irrelevant to topic
· Lack of volume control and intonation
· Lack of retrieval

6. Coping Techniques
· Preoccupations with certain objects or subjects for long periods of time
· Repetitive movements (self stimulating behaviors) such as rocking, twirling, flailing or looking at one’s fingers at close range
· Restricted patterns of interest
· Inflexible adherence to specific routines or rituals
· Correctness

7. Other
· Abnormally sensitive to sound, touch, or other sensory stimulation
· Running behavior (no internal boundaries)

My next blog will talk about the time consuming nature of the work with autistic individuals.

An Incomplete Attachment and Understanding Autistic Behaviors

What does an incomplete attachment look like? One only needs to look at any child, adolescent or adult on the autism spectrum continuum to answer this question. The behaviors one sees with such individuals seem to be confusing and do not make sense. No two individuals with autism seem similar or manifest the same behaviors. If one thinks about autism from the perspective of an incomplete attachment then the developmental delays and the children will make sense.

From this perspective, the child has not had the benefit of a completed attachment. As all infants, she is born into the unconscious ready to be brought out in relationship to the caregiver, but this does not happen. The child is in a waiting state. He or she is waiting for a completed attachment. Thus the behaviors that one sees in the autistic child are the result of not having had a completed attachment. The behaviors are what can be called “coping” and “state of existence” behaviors. Each child will cope differently to the circumstance and thus will have different behaviors as compared to another child. A key point to mention is that because of the incomplete attachment the child is left without the ability to use herself both in body (lacks self-agency) and mind (lacks theory of mind). The ability to use one’s self will vary from child to child. Some children will be more conscious of him/herself and thus have more access to use themselves in relationship to others. Thus we have a continuum of ability, which is typically known as the functioning level of the individual on the spectrum (low functioning, high functioning and Aspergers).

To explain it in a little more depth, the behaviors one sees in autistic individuals are unconscious behaviors that have been dissociated or separated within the child. It is like the child is of two minds, the conscious mind and the unconscious mind. This is true of all human beings. Within the autistic child they are more dissociated and split from their emotions than others who appear to develop “typically.” Dissociation does not give us the complete picture. From a broader perspective, one can say that the child on the autism continuum has a lack of a completed attachment, has a dissociated sense of self, has developed coping mechanisms to manage the situation, is unable to use one’s self in relationship to others, seems to lack the knowledge of their own emotions and is unable to access those dissociated emotions and finally uses indirect mechanisms to grow in relationship to others. The treatments that seem to help this population are actually helping the child to become more and more conscious and integrated as a human being. Below I have compared the developing autistic child to the developing “typical” child.

“Typical” Child
1. On a continuum – from partial sense of self to a well integrated sense of self
2. Attachment has occurred
3. Ability to use oneself to get needs met. The degree that the individual can do this will vary widely
4. Knowledge and ability to know one’s emotional feelings
5. On a continuum has access to use one’s emotions in response to the other
6. Transference occurs in the relationship in a way that is typically understood
7. Can use the relationship to grow

Autistic Child
1. Varying degrees of dissociated sense of self
2. Lack of a completed attachment
3. On a continuum - from no ability to use oneself in relationship to another to ability to use oneself on a limited basis
4. Lacks knowledge of one's emotional feelings
5. Does not have access or ability to use dissociated emotions
6. Transference expressed in ways unfamiliar to most (indirect). Transference is fragile
7. Does not directly use the relationship to grow (indirect usage)

In my next blog, I will take the behaviors of the individual on the autism spectrum and make sense of them.

Friday, April 10, 2009

Relational Therapy and an Incomplete Attachment: A New Look at the Etiology and Treatment of Autism Spectrum Disorders

Autism is like being trapped in an enclosed maze. Within this maze it is dark and scary. You can see out, but no one can see in. You are in a perpetual state of terror with no access to others or a way out. You feel the walls closing in and can do nothing about it. You are screaming inside, but nobody can hear your screams. You are frantic. You keep running in circles to no avail. Alas you run out of steam. It is futile, hopeless and depressing. It is no use. No one can see you. You have become a lost child forever. You have become forgotten. Lost in a never-never land. It is a never-ending hell on earth. The only thing you can do is wait and hope that you will be discovered.

Mystery and controversy surround the etiology and clinical work with children diagnosed with an Autism Spectrum Disorder. Although the etiology by many is considered to be unknown, the majority of professionals working in the field of autism and parents of autistic children consider autism to be a neurological disorder. From this perspective, the clinical work with this population focuses primarily on techniques such as Applied Behavioral Analysis, modeling and social skills development. The work done thus far with this population should be commended and not discounted. We are now ready to augment the present state-of-the-art work with this population by introducing Relational Therapy. This therapy is similar to Floortime in that it emphasizes the relationship between the child and the therapist or caregiver. The major difference is that Relational Therapy introduces a treatment process (plan) that at its core is based on understanding the etiology of autism. Once the etiology is understood, then the therapist or parent can understand how to engage with the child.

From this alternative perspective it is my belief that children on the spectrum have not had the advantage of a completed attachment. I call this perspective “Incomplete Attachment.” Thus it is my belief that what one sees when observing children on the spectrum is a child who is waiting for the attachment process to be completed. The child is doing the best he/she can to cope with this predicament. All the behaviors such as flapping arms, nonverbal communication, echolalia, lack of responsiveness to others or inability to communicate one’s needs, can all make sense when taken from this perspective.

These writings will go into detail about this perspective and how one works with children, adolescents and adults from this perspective. It is my belief that Autism Spectrum Disorders can also inform our understanding of psychological development in general and specifically Theory of Mind. Autism Spectrum Disorders can be viewed as a window into the understanding of how all “typical” individuals develop psychologically. It is my hope that these writings will lead to a beneficial dialogue within the autism community and beyond.

As a point of reference, I am presently working as a marriage and family therapist in West Los Angeles. I specialize in Autism Spectrum Disorders, depression, anger management, assertion training, anxiety and primitive states. I have worked for many years with children, adolescents and adults on the autism spectrum continuum. I have also provided trainings and support groups for parents of children with autism. I am now running groups for college age students with developmental disabilities. And finally I have made presentations on this subject at numerous conferences and meetings.

My next blog will discuss the Incomplete Attachment in more depth and begin to discuss the meaning of “autistic behaviors.”