Monthly Archives: February 2013

What Does Psychoanalysis Have to Offer the Treatment of an ASD Child?

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What does psychoanalysis have to offer models of intervention? There are several features of psychoanalytic theory and technique that can benefit the treatment of ASD children and their parents.

First, the training and experience of psychoanalysts is unique in that it involves developing an intimate, dependent relationship with a person in need, with the focus of attention on that individual’s inner world and also in the interaction between the two analytic partners.  This attention to what is going on in the relationship, in the moment, contributed to by both partners, and understood at a deep level – both symbolically and in the implicit and nonverbal – allows for a different kind of co-creative meaning making. I would consider this to be a unique competence of the psychoanalyst.

Second, psychoanalytic training and experience includes a high degree of “pattern recognition”, for example, an ability to recognize symbolic representations of strong emotions within relationships, and combinations and sequences of emotion and psychological efforts at self-protection or defense. Illustrations of these patterns might include a child’s remark about a tornado followed by an association to the child’s younger brother. Another example might be a child’s attempt to protect him or herself from threatening aggression coming from within by turning away from what is provoking the sense of threat or by retaliating against an imaginary external threat. Refined pattern recognition allows the psychoanalytic clinician to take a less linear approach to the treatment of ASD children in that partial or relatively incoherent symbolic representations are easier to spot and to use in understanding the child’s experience and communicated to the child. This often can be helpful even if the child is not considered to be at a level capable of apprehending such a communication according to other models.

Third, psychoanalytic training and experience requires learning a great deal about yourself, that is, about the clinician him or herself. This self-knowledge might include the clinician’s personal organizing fantasies, for example, to rescue a suffering child. It might include the stressors that challenge the clinician’s sense of him or herself, such as making a mistake or causing pain in another person.  It might also include the individual’s particular reactions to emotional challenges and the characteristic means he or she uses to deal with intense affect – to withdraw, for example, or to try to undo some perceived injury.

Psychoanalytic training also allows for a deeper and more comprehensive understanding of parents – how adults cope with stress, how they transmit early relational patterns from one generation to the other, how they grow. Psychoanalysts learn how to tolerate anguished attacks without taking them personally, how to help a suffering person move from the perception of being a victim to that of taking an active role in recovery, and how to move into a collaborative role with another in the context of threat.

Psychoanalysis “off the couch” is valuable not only to the psychoanalytically trained clinician, but to the team that treats these children. I believe that a team that includes specialists in psychoanalysis or psychodynamic psychotherapy, occupational therapy, speech, and education should treat all children with autistic spectrum disorders. Pediatricians or pediatric specialties are also sometimes needed. It is very challenging to organize a team into a collaborative partnership in which roles are clear and compatible and in which there is adequate communication, but it is possible. It is also challenging – though I also believe possible – to plan such a treatment that is affordable and not an unbearable burden for parents.

Read this blog in Spanish. 

Photograph by Ginger Gregory

Similarities and Differences Between ESDM and DIR

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The similarities are that they (1) Both see autism as a neurobiological disorder whose course can be significantly affected by the early caregiving environment; (2) Both work with very young children, often 2-years old or even younger; (3) They both organize their models around a linear developmental framework that refers to “normal development”, in other words – at this age the typical child should have this competency, and then at this other age, he should be able to do this; (3) They both include the parents – but to varying degrees; (5) They both have a prescribed set of techniques that the therapist has to master; (6) They both use videotape as a teaching tool; (6) They both track progress through the accomplishment of specific developmental competencies that are set forth in their writings (such as the achievement of language goals or goals in pretend play).

The differences are that (1) ESDM derives from ABA (the behavioral method that Lovaas introduced in the 60’s), though not DTT (discrete trial training), while DIR derived from observations that the young children in a disadvantaged population had a high incidence of developmental disorders; (2) The ESDM is a manualized treatment that involves the clinician to chart goals and results for each session, and the DIR – while requiring adherence to specific techniques – does not require a specific number of particular responses from the child within a  time frame; (3) ESDM has impressive empirical evidence to demonstrate its effectiveness including a very large n (660) and following the children from 6 months to 36 months; DIR is only just now starting to do efficacy studies (there are some long term follow up studies but only one empirical study that I know of, following children 12 months; (4) ESDM really emphasizes starting at age 2 and though DIR also likes to start early, it often doesn’t  start that young; (5) ESDM likes to maintain the “coherence” of the intervention by NOT involving other disciplines like OT and speech, believing that this intervention is comprehensive enough in itself, whereas DIR from the beginning has worked with an interdisciplinary team; (6) ESDM emphasizes language acquisition as perhaps its critical first goal, whereas DIR emphasizes the establishment of joint attention first, believing that language acquisition will follow; (7) DIR emphasizes visual spatial orientation more than ESDM, believing that this is frequently disturbed in ASD children and interferes with social engagement; (8) The DIR technique emphasizes using affect and the relationship (joint attention) more than ESDM; (9) DIR almost always works by coaching the parents and not the therapist working directly with the child, whereas, ESDM often has the parent in the room but has the therapist working directly with the child and the parent watching – then they have separate sessions to teach the parents.

Evidence that DIR and ESDM are learning from each other or at least coming closer together is as follows: (1) Sally Rogers talked about the importance of the ESDM initiative to train parents; this is similar to the original technique of DIR of coaching parents. (2) Although Sally Rogers emphasized the coherence of the treatment and how other disciplines were not involved in order to accomplish this coherence, some of her slides included involving OT and speech specialists, so I imagine they are included if only as consultants or advisors. (3) Serena Wieder talked about the effort to obtain validation in empirical research for DIR. (4) The DIR intervention is presented as designed to suit the individual child – in this way distinguishing it from ESDM, yet the intervention model follows a prescribed path that takes the child and parent from one level to the next in a linear progression. (5) Although Dr. Wieder also presented DIR as attending to the inner world of the child, she did not show us examples of this in her films. (6) In addition, the DIR training does not seem to produce clinicians – excellent though they tend to be – who are familiar with this particular domain child psychotherapy; that is, DIR clinicians generally are skilled at working with parent and child at the lower “levels” of development as defined by the DIR model, but not so much at the higher level of symbolic function.

Read this blog in Spanish. 

Photograph by Ginger Gregory 

IPMH January Weekend III: Serena Wieder on Autism Spectrum Disorders

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Dr. Wieder talked about her original collaboration with Stanley Greenspan. She wanted to do outreach to underprivileged population. They started long term study of an underprivileged population to answer the question of how do you know that a child is “on track”? The first thing they learned was they had to deal with regulation and shared attention. They then realized they needed to learn more about language development and sensory integration and they brought in specialists in these fields. Then what the infant brings into the world, the individual differences. They created an intervention for children with developmental disorders, primarily ASD – DIR. “D” is for development, “I” is for individual differences, and “R” is for regulation.

Wieder states that the basis for development and for treating autism is developing reciprocal relationships between parent and child. DIR introduced a major paradigm shift in intervention from a focus on behavior to one on affect and relationships. The idea is affect is central to learning and that emotions drive early cognitive development. The approach involves treating relationships and not just the child. It assumes that every child has an inner world even if he or she cannot express it, that everyone has individual differences and therefore needs an intervention that specific to him or her, that an interdisciplinary approach is necessary, and that competencies come from experience instead of from training. These features of DIR distinguish it from the ESDM model as it is described. DIR proposes a structure to bring together a step-wise model of the developmental process with the individual features of the child, and features of the environmental, including the parents.  There are 6 “core developmental stages or processes called The Functional Emotional Developmental Levels”.

Wieder also points to the biological/neurological origin of autism, referring to autism as a disorder of neural connectivity that interferes with the connection of affect and intention to the child’s ability to sequence actions and also to relate, communicate, and think (Just et al, 2004, 2007). When sensory motor processing and challenges in language comprehension and visual spatial knowledge derail development, emotion must be brought into the intervention as early as possible to strength the connection between sensation, affect, and motor action.

Dr. Wieder stresses that DIR initially emphasizes the relationship with the parent. She says that DIR has influenced the field; now behaviorists use developmental concepts and the two groups may be coming closer.

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IPMH January Weekend I: Alice Carter on Autism Spectrum Disorders

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In the morning Alice Carter started out talking about internalizing problems in early childhood, such as anxiety or mood disorders. These are distinguished from externalizing disorders that include behavioral problems, such as hyperactivity and disruptive behaviors. Internalizing problems attract less attention from adults – both parents and researchers – than externalizing problems, but there are approximately the same proportions of young children suffering from both. Longitudinal studies offer evidence that these problems have stability over the course of childhood. Contrary to popular ideas, these difficulties are not so hard to distinguish from temperament or childhood “stages”; parents are good at identifying them in their children. Studies of young children do not find significant differences in the prevalence of these problems in boys versus girls; differences in socialization or parenting may account for the fact that by adolescents, there are more girls than boys with internalizing problems. 

Carter pointed out that we expect children to develop a set of social-emotional skills to help them in self-regulation and in relationships. These skills include the capacity to pay attention, compliance, empathy, mastery motivation, interest in peers, and play. Examples of responses of parents who confirm internalizing problems in their children on the ITSEA test (Carter and Briggs-Gowan 2006), are “looks unhappy sad without reason”, “worries a lot or is very serious”, “is very worried about getting dirty”, “hangs on you or wants to be in your lap when with other people”, or “is quiet or hangs back in new situations”. Carter developed the ITSEA and BITSEA (shorter, only 42 items).

In the afternoon, Carter discussed the early detection and intervention for autistic disorders in early childhood. This is important both because of the frequency (recent epidemiological estimates of 1/100 children diagnosed with ASD, boys 4 times more than girls) and because of the importance of early intervention. Interventions have the greatest impact when occur before 3 years old.

Because no blood tests have yet been identified, we must rely on behavioral observation. Most people identify the three core areas of significance as (These are also the criteria in DSM IV): 

1. Social interaction.

2. Communication.

3. Repetitive restrictive behaviors.

Carter says that the absence of expected social behaviors is more critical than the presence of odd social behaviors. There may be oddities of speech such as repeating words and atypical intonations such as questioning intonation when answering, “video speak”, or pronoun reversal.

Carter showed us videos demonstrating these signs. 

1. A 31-month old boy picked up the bubble gun and walked to his mother (who is holding the bubble solution), without looking at her, saying, “OK bubbles”. He tried the bubbles, repeatedly saying, “OK, bubbles” without variation in tone. He gave his mother eye contact twice during the sequence, but whenever he spoke, he averted his gaze, failing to integrate eye contact and verbal communication. 

2. In a film of another boy, there is a balloon, giving the adult and child the opportunity for joint attention. This child of 30 months is high functioning but when he speaks to the researcher, he has an unusual inflection and he does not look at her, nor at his mother. He is not muted, having a wonderful time, but not sharing his fun with anybody. He is not pointing to anybody.

3. There is a film of another child of the same age, running back and forth in front of the mirror. When left to his own devices, he would continue to run back and forth, repeating long sequences from a video he knows; he exhibits some unusual hand movements. He sometimes will jump up and down in place and wave his arms. He is also giving himself visual stimulation in an atypical gaze, to the ceiling, and he is toe walking. 

4. Another child does not respond to his name. He chooses one toy and does not explore the others. He does what is called “finger flicking” with his non-dominant hand. 

Carter says that children with ASD are like snowflakes. There is great heterogeneity – in terms of symptoms, cognitive abilities, linguistic functioning, behavior problems and adaptive behaviors. 

An important source of data is birthday party videos (Dawson et al, 2004), for example, one-year-old birthday party videos. Early markers across questionnaire and observational measures include proto-declarative pointing (points to show things far away); following a point; bringing object to show parent; interest in other children and people (not just when they want something from you); imitation (a real problem for learning); responding to name (looks right at you when you say his name); pretend play (hug or feeds dolls or stuffed animals); repetitive stereotypical behaviors (puts things in a special order over and over, repeats movement over and over). Pretend play – you also have to see what happens if you try to add to it or interrupt it. 

Though it is one of the most important goals in an intervention, developing greater competency in pretend play is one of the most difficult challenges. Kids will do stories they see on TV or in videos, but real creative pretend play is hard to teach. There are other things you can change more easily. For example, if you can be taught that you have to look at someone and say hello because that is socially acceptable. Also, manners are helpful in terms of your relationship to the world. Parents go with kids throughout different settings, so they are very helpful in terms of generalization because they can coach the child to use the skill in all the different settings that they move through.  Teaching children with ASD to generalize from one setting to another is very difficult. They also have what is called “sticky attention”. If you shake a rattle, the child will look at it, but then if you pick up a rattle in the other hand while still shaking the first rattle, the child with ASD will continue to look at the first rattle, while the neuro-typical child will look at the second. Parents tend to both over-report problems or normalize behaviors, so also use observation. 

Interestingly, there are some tasks that children with ASD do more easily than neuro-typical children (Kaldy et al, 2011). In passive viewing task, kids sit and watch a picture of a dot, and the longer the kid looks at a dot, the bigger the dot gets. In this task, the more distractors the harder it is to find the target, yet the more distractors you add, the better the ASD kids are in relation to their age peers. How do we use skills such as this to enhance their learning in other areas? If you look at pupil dilation that shows arousal, they do better because they maintain this aroused vigilant state during the trials better than the typical kids. 

Parental well-being: One of the most important jobs in helping a family with an ASD child is the support of the parents. They are faced with daunting challenges, for example making complex decisions about intervention plans (http://www.supportingchildcaregivers.com/a-cast-of-thousands), understanding the minds of their children when the motivation of their behaviors are so opaque, managing dysregulated behaviors, balancing the needs of all family members, including siblings, etc. These parents have hugely high rates of stress, depression, and anxiety (Davis & Carter, 2008). They struggle with feelings of confusion, guilt, and frustration. It is hard to explain the diagnosis to friends and family members who may not support the diagnosis.  

In numerous studies, Carter has demonstrated that sensory hypersensitivity exists, and it exists aside from psychiatric diagnoses (Ben-Sasson A et al, 2010). However, she points out that there is no evidence that sensory interventions are effective. She also responded to questions from the audience about dietary treatments, neuro-feedback, chelation, and many other recommended treatments for autism. Carter said that some of these interventions may have a positive effect, but they are not scientifically validated. 

References

Ben-Sasson A, Carter AS, Briggs-Gowan MJ (2010), The development of sensory over-responsivity from infancy to elementary school, J Abnorm Child Psychol, Springer Science+Busiiness Media, LLC 2010.

Carter, A. S., & Briggs-Gowan, M. J. (2006). Manual of the infant toddler, Social-emotional assessment. San Antonio: Harcourt.

Davis N, Carter AS (2008). Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: Associations with child characteristics, J Autism Dev Disord 38:1278-1291.

Geraldine Dawson; Karen Toth; Robert Abbott; Julie Osterling; Jeff Munson; Annette Estes; Jane Liaw, Early Social Attention Impairments in Autism: Social Orienting, Joint Attention, and Attention to Distress, Developmental Psychology 2004; 40(2): 271-283.

Kaldy Z, Kraper C, Carter AS, Blaser E, (2011), Toddlers with Autism Spectrum Disorder are more successful at visual search than typically developing toddlers, Dev Sci Sept 14(5):980-8.

Read this blog in Spanish.

Photograph by Ginger Gregory