Thursday, May 28, 2009

Autism and Dissociation

Through the lens of an “Incomplete Attachment” I have described that the autistic child is experiencing dissociated states. What does this mean? From my perspective, the child has many parts of himself that have not become integrated as a whole. These aspects of the self have not been validated and recognized by “an other” so the child, in turn, cannot use and see himself. Thus the different parts of this child become dissociated and cannot work together to the benefit of the child. We can say that this child does not have the ability to go from one part of himself to another. The child also cannot go within himself to retrieve these dissociated parts.

How can I recognize dissociation in an autistic child? Dissociation is easy to recognize. We all have aspects of dissociation, but it is more profoundly seen in Autism Spectrum Disorders. The following are examples of dissociation: 1) reduced sense of pain – the child may burn himself, but not demonstrate any outward behaviors that say, “I am hurting.” The pain is there and he feels it, but he is split off from his ability to claim it and name the feeling, 2) Exceptional savant skills – such as extraordinary ability to remember days of the week of birthdays and dates associated with events, ability to do mathematical calculations that others can only do with the help of a calculator or great musical and artistic abilities. These abilities seem to coexist with what appears to be severe disabilities. Most people observing such a mixture of behaviors would be confused and conclude that there must be something “wrong” with a person who on the one hand has great musical ability or artistic ability, but cannot talk. I would say this is an example of dissociation in that the emotions are split off from the intellect of the person, 3) Cannot shift thinking from one subject to another – this is an example of not being able to go from one part of the self to another. The individual is demonstrating on the outside of himself what is occurring on the inside of him. In other words, his inability to go from one part of himself to another, and 4) the child can think through mathematical problems, but cannot think through and understand social interactions – the child has access to his intellect, but no access to the emotional parts of himself. The emotional side is harder to access if you have never had an attachment. It is through an attachment that one feels understood and seen and in turn can talk and have access to the emotional parts of one’s self.

These are only a few examples of what I think about when observing the autistic person through the lens of dissociation and an “Incomplete Attachment.” When one thinks about autism from this perspective than one can have hope that the child can develop into an integrated person. The work with the autistic person is to help them to become more conscious of the split off parts. This includes helping them to name their feelings along with the development of a trusting relationship with “an other.” As they become more conscious of themselves their dissociated parts will begin to work together.

Friday, May 15, 2009

Autism and Communication

Getting one’s needs met and to exist happily in one’s family, community and beyond is dependent on the ability to communicate. As non-autistic individuals we can use ourselves to communicate our needs and express our feelings. The autistic individual depending on their functioning level, has anywhere from extremely limited (nonexistent in some) to some ability to ask for their needs to be met. Some people with autism seem to communicate by perseverating on a topic that seems to not relate at all to whatever the topic might be. For example, one child may become fixated on televisions and only be able to talk about this subject, no matter what else is being discussed. It is not unusual for autistic individuals to seem to come out of "left field" with what they might say. For example, the topic may be "going to the grocery store and what will be bought at the store." The child may say, “you are pretty.”

There are also individuals who are nonverbal, those who use echolalia and still others that can only express their needs by reversing their pronouns. When they want a cookie to eat, instead of saying “I want a cookie,” the child may say, “you want a cookie.”

Let’s make sense of what is going on. If as I am suggesting the child has not had the benefit of an attachment, lacks the ability to use him/herself in relationship to others and is also in a state of dissociation with varying degrees of consciousness then I would continue to propose that the child’s ability to communicate is going to be compromised. Let me explain how these different elements contribute to not only problems in communicating, but also relating to others.

It is important to remember that the autistic individual wants to communicate and in fact is always communicating about himself even though he may be nonverbal, echolalic or reversing pronouns. He is like any human being in that he has a need to communicate. Unfortunately, because he has had an incomplete attachment, he cannot identify his feelings, which are dissociated, and therefore cannot use those feelings to express his needs. In other words, he has not developed to a level where he has self-agency. This means he literally cannot ask for anything for his own benefit. This is not a physical problem, but instead a “developmental problem” that can change over time.

It is my opinion, that what one sees with the nonverbal autistic child is the reverse of what one sees with a “typical” child. I call this phenomenon “Inside out, upside down.” In other words, the unconscious part of the child is on the outside and the conscious part is in the inside. That is why some nonverbal autistic children seem out of control and low functioning, but with the use of a computer can communicate beautifully in writing. This is a very good example of the split or dissociation of the self. Most people are unfamiliar with seeing the ‘unconscious.’ Because most people are unfamiliar with the workings of the unconscious, autistic individuals are constantly misunderstood.

The phenomenon of echolalia is also something that can be understood. One first needs to remember that the autistic child has minimal and varying (depending on their functioning level) ability to use oneself in relationship to others. Also it is important to remember that a lack of attachment precludes one from being able to use one’s self. Thus echolalia is the result of not being able to use one’s self. The child only has access to what they hear. They may hear “do you want a cookie?” Developmentally all the child can do is mimic the other person. There is no awareness and ability to use the self in response to the other. Thus the end result is a repetition of what the child heard.

The child who reverses his pronouns and uses ‘you’ to mean ‘I’ is beginning to use his self with others. The child uses ‘you’ because it is safer than ‘me or I.’ The autistic child does not feel safe in the world. Everything is confusing, awkward and anxiety producing. The use of ‘you’ as it refers to the self is another example of dissociation. As I mentioned before the child is split. As the child develops and he becomes less split and gains more agency, he will then move to using the pronoun ‘me’ and finally as he has more and more access to himself, he will be able to use ‘I.’ There seems to be a direct correlation to the use of ‘I’ and ability to know and access feelings and use them in relationship to others.

Now lets look at why the communication of autistic individuals appears inappropriate. First of all, I believe that an autistic individual is always communicating his state of existence. Unfortunately, most perceive these communications from their own experience, which includes having completed the attachment process. In working with autistic individuals, many try to extinguish the “odd” behaviors of the child. In doing so, we are not understanding the message the child is trying to communicate through his strange behaviors. We in a sense are helping them feel misunderstood versus understood and not seen versus seen. Instead these communications need to be understood within the context of a child who has never attached and cannot use the self to communicate. Every behavior that the child uses can be understood and must be understood so that the child can gain understanding and recognition, which are precursors to being able to attach. Our work with the autistic person is to understand, validate, accept and recognize the autistic person. If the caregiver or professional can recognize and see the child, then the child can start to see him or herself.

Examples may help you to understand what I am communicating. I visited a three-year-old nonverbal boy, who had never seemed to play appropriately with his toys. In observing him, I noticed he was picking his lips. Instead of telling him not to pick his lips, I said, “you are telling me that something is going on around your lips and your inability to talk.” He looked at me and then played appropriately with a toy. Another example will help to highlight this point. I worked with another boy who liked to watch videos. He had certain ones he wanted to make sure I saw. One day, he showed me a video, which explained a complicated family dynamic. I interpreted the dynamic as it related to his family. As I was able to do that, he could begin to talk about his own personal experience. These are examples of how one interprets and uses projection with autistic individuals to gain access to their feelings (I will discuss how this is done in another blog).

In concluding this blog, I want to restate that the perseverations, the out of context communications, the use of pronoun reversal, echolalia, nonverbal communication, to name only a few, can be understood through the lens of an “Incomplete Attachment” which leaves the individual in a state waiting for the completed attachment and without access to self or what I call self-agency.

Friday, May 8, 2009

Play Dates and the Autistic Child

The desire to have one’s child interact with and to be accepted by others is the wish of all parents. When this does not occur the parent may become concerned, anxious or worried. Parents of autistic children face this dilemma on a daily basis. They are very aware that their children interact differently and display behaviors that are confusing to most.

The autistic child’s ability to interact and engage with others is limited and varies on a continuum from complete noninvolvement with others to sporadic and limited involvement. For the autistic child involvement with others can be confusing, intimidating and frightening. Autistic children can benefit positively to the exposure to other children through play activities.

Some suggestions to consider in setting up play dates:
· Begin slowly and with patience. First, have a conversation with the parent of the child you want to set the play date with. Come up with a simple way to educate the parent about your child’s behaviors and your desire to have the two children play. If the parent is receptive, the next step is to talk with the non autistic child and parent together about your child’s desire to play. Next talk to your own child about your intention;
· Set up the play date in your home. Your child is familiar with this environment;
· Limit the time based on your child’s ability to be with others. I would suggest a half hour. Decide on an activity that you know that your child can engage in. Supervise the two children in the activity. If they seem engaged let the children continue the activity under your watchful eye;
· At first parallel play may be all your child can tolerate;
· You may want to have multiple activities available if the children do not respond to the initial activity;
· Leave time for cleaning up, a story and refreshments;
· Continue with short play dates, but increase the time with others as your own child can tolerate longer interactions;
· After the play date you may want to check in with the other parent to see how her child handled the play date. If things went relatively well, you may want to continue such interactions. It is important to have a willing other parent and child that feel comfortable in supporting these activities.

As a point of caution, do not give up. This will be a slow process, but one that can be rewarding for all involved.