Tag Archives: ASD

Bathroom Problems I: Soiling or Encopresis

Encopresis

Many of the children whose parents consult me suffer from a condition called encopresis, or soiling, a distressing problem that is diagnosed in children older than 4-years old. Encopresis usually starts with constipation. If a child experiences pain when passing a hard or large stool, it is common for the child to tighten up and hold back in response to the urge to defecate. This of course makes the constipation worse, and often soft stool from higher in the gut leaks around the hard mass in the colon, causing soiling.

The first step in dealing with this problem is to go to the pediatrician. Good medical care is essential to the treatment of these symptoms. If the constipation is not treated the withholding is likely to continue and may cause anatomical changes in the gut such as stretching of the muscular intestinal wall. Children who suffer from chronic constipation may also develop a disturbed coordination of muscle function in the anal sphincter. Medical treatment often involves stool softeners that draw water into the gut and soften the stool, making it easier and less painful to pass. There are other more vigorous and more intrusive interventions that can be used if necessary.

Pediatricians also often recommend behavioral plans. The most effective behavioral plan is for parents to gently but firmly insist that the child sit on the toilet after mealtimes – usually breakfast and supper – twice a day for 5-10 minutes. The natural movements of the intestines after meals aid in defecation. Sometimes small rewards or star charts help motivate children to follow through with this plan.

If this is a typical pediatric problem, why is it a concern for a child psychiatrist? The main reason is that there are three groups of children who might come to me for another reason who are also prone to having encopresis. The first is anxious children, the second is aggressive children, and the third is children with developmental problems such as attention deficit disorder (ADHD) or autistic spectrum disorders (ASD).

When I describe anxious and aggressive children as belonging to different groups I am only referring to their outward behavior. Most anxious children are afraid of the destructive potential of their own aggression (even if their general behavior is timid and withdrawn). Similarly, children with aggressive behavior usually struggle with the fear that their aggression will get out of control and hurt someone – especially a family member or themselves. What is a natural response to the fear of something dangerous getting of control? Control it! In other words, hold it in. Since children make meaning with and about their bodies even more than adults do, they “hold it in” concretely and physically. This psychological meaning almost always occurs simultaneously with the biological meaning of the threat of passing a hard stool. In my office practice, it is common for a child who allows himself to freely play an aggressive theme, such as dinosaurs biting each other, to interrupt the play and go into the bathroom to poop.

Children with developmental problems are even more interesting. In addition to all the other reasons mentioned above, they have difficulty picking up their body’s cues such as the urge to defecate. This is because they have trouble paying attention to their body’s signals and also because they sometimes cannot decipher them. Some children with ASD need to be told to put on a coat or mittens when it is cold outside since they don’t notice the cold feeling without help. (Readers may be surprised when I link the diagnoses ADHD and ASD in the general category of developmental problems, but I think that is the most sensible way to understand them.)

Helping children with their fears and helping them learn to pay attention to the signals their bodies send them is very important, but nothing can take the place of a regular bathroom routine of sitting on the toilet for 5-10 minutes after breakfast and supper. So why do parents find this so difficult to do? One reason is that the child who is afraid of passing a painful stool will object, and parents of fearful children often have trouble insisting that they face challenges that frighten them. Another reason is that the child with attentional problems or the child who has trouble reading body cues will often “tune out” while sitting on the toilet (sometimes get lost in a book). While “tuning out” will sometimes not prevent a bowel movement, the child who is not paying attention to his body will not learn how to respond to his body’s signals. That is why I do not recommend letting a child read or play with an iPad while sitting on the toilet. It is difficult, but it is a good exercise for both parent and child to help the child tolerate this routine.

Read this blog in Spanish.

The Challenge of Making Transitions

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Just before I left on vacation, a mother of a child in my practice asked me why it was so hard for her 6-yo son to make transitions. I was rushing to get ready to leave, so I sent her a quick email promising to respond more fully when I had a chance to think about it. I have had her question in the back of my mind and was especially struck by it when I arrived in Europe and experienced jet lag. It occurred to me that jet lag was a good metaphor for the kind of transition the mother was asking about.

First of all, her child is one of those highly sensitive children I refer to as “race horses”, of others in the literature have called “orchids”. He is extremely intelligent but sometimes retreats to infantile behavior patterns, and he often reacts with extreme distress in the context of transitions – even simple daily transitions such as getting up and getting ready for school in the morning or leaving play to go somewhere or do something else. This problem is interesting because it gets mixed up with all sorts of other categories of problems – such as problems with compliance (behavior problems) or sensory over-responsivity problems (SOR) (Ben-Sasson et al, 2010).

I think there are reasons for this confusion.As writers on “orchid” children point out, it is easier for children with certain temperamental characteristics to readjust to changes in their environment. (I chose the above photo of young Indian dancers because I imagined – though I do not know these children – that the girl on the left has an easier temperament than the girl on the right.) These delicate children are often much harder to parent than children with easier or more resilient temperaments (“dandelions”), and parents and child often initiate problematic interaction patterns early on that can influence the child’s developmental trajectory in an unfortunate direction. It then becomes the job of the child therapist to help the family (child and parents) correct this misdirection.

The kinds of problematic patterns that are characteristic of this situation typically involve mutual over-control. That is, children who feel highly stressed by demands for change (in other words, transitions) often try to exert a counterbalancing force by controlling their environment (their parents, included). Parents may respond either by engaging in a control struggle with the controlling child or by giving in, or by both (Granic, 2006). When these patterns are repeated, they become more firmly rooted in family behavior. I refer to this as building stronger infrastructure for the problem cities (metaphor for problematic relational patterns such as struggles in families) so that it is easier to get there and stay there. Of course, it is better for all involved to build strong infrastructure for the cities that represent more adaptive behavior patterns such as collaboration, but when people are stressed, they often choose the behavior that takes less energy (from the point of view of managing emotions and using reflective capacity) in the short run and more energy in the long run (having to repair the ruptures that struggles and fights cause in the family).

The job for child therapists is to work with child and family to “break the habits” of the problem behaviors and substitute more adaptive patterns. This is done by a variety of techniques including gaining insight into the meanings underlying the behavioral reactions of child and parents and supporting the emotional regulation of all concerned, and then … practicing the new more adaptive patterns again and again and again. I will write more about this important aspect of the topic in a future posting, but I will limit myself here to the mother’s question of “why?”

Let me return to the metaphor of jet lag. My intention is not only to respond to “why” a child has trouble with transitions, but also to offer a way of empathizing with the irritable child. (Often, a parent empathizing with the child allows her or him to better imagine the child’s mind and this can facilitate the parent’s choice of response to the child’s demanding or oppositional behavior). I found a good article on jet lag that describes it in terms of whole organism dysregulation (Vosko et al, 2010). Circadian rhythm – sleeping longer at night and less during the day – is one of the first organizations to emerge in the developing newborn (Sander, 2008). It is achieved through a series of oscillatory networks that include a master oscillatory network in the suprachiasmatic nucleus (SCN) in the brain and also sensitivity to environmental light cues (Vosko, p. 187). During jet lag, the paper continues, abrupt changes in the environmental light-dark cycle desynchronize the SCN from downstream oscillatory networks from each other, disrupting sleep and wakefulness and disturbing function (ibid, 187). This kind of “circadian misalignment” can lead to a series of symptoms, including major metabolic, cardiovascular, psychiatric, and neurological impairments (ibid, 187). During this trip, as usual, my jet lag “took over”. Although I intended to stay awake and enjoy the company of my friends and the new landscape, I was compromised in my ability to do so. The feeling of dysphoria came in waves; sometimes I felt my old self again and other times I felt tired, irritable, and even sick.

The benefit of this metaphor is that it emphasizes the notion of whole human being “organization”. Many problematic behaviors result from a disorganization of adaptive patterns of functioning. The human organism is constantly working to keep itself on track and to accommodate small bumps and disruptions. It is when the reorganization does not happen smoothly, when things fall apart, that a “symptom” appears. The symptom can be physiologic as well as emotional, just as in jet lag. Children who have delicate temperaments or other developmental reasons for high sensitivity (such as children with ASD, uneven development, trauma, or SOR) are particularly vulnerable to this problematic disorganization.

Consider all the demands for reorganization that a child has to respond to on a daily basis: She has to wake up, changing from a sleep state to an alert state. She has to get up and get ready for school, requiring many transitions from the multiple small tasks involved in washing and dressing. She has to eat breakfast, even if she is not hungry at the time. She has to say goodbye to home and parents and make a big shift from a relatively dependent position to a more autonomous position in terms of initiative and compliance. When she gets home from school she has to deal with other important transitions. Don’t think for a moment that greeting a beloved parent is necessarily going to be a pleasant experience; the transition from a holding-it-together-at a higher-level-of-organization-state at school to a more relaxed and dependent one at home is often bumpy! In addition, often parents of sensitive children give them aids to help them keep organized in the transition, such as video games. As I have mentioned in another posting, these games work very well to keep a child organized because they provide an effective external regulator. When this external source of regulation is taken away abruptly, it can be expected to cause great distress. Even a book, a much more adaptive regulating activity, can cause distress when discontinued.

What is the answer to these problems? I will respond in a subsequent posting!

Read this blog in Spanish.

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, DOI 10.1007/s10802-010-9435-9.

Granic I (2006). Towards a comprehensive model of antisocial development: A dynamic systems approach, Psychological Review, Vol.113, No. 1, 101-131.

Sander, L. (2008). Living Systems, Evolving Consciousness, and the Emerging Person, New York: The Analytic Press.

Vosko AM, Colwell CS, Avidan AY (2010). Jet lag syndrome: circadian organization, pathophysiology, and management strategies, Nature and Science of Sleep, https://www.dovepress.com/jet-lag-syndrome-circadian-organization-pathophysiology-and-management-peer-reviewed-article-NSS.J

“A Healing Place”: Part III

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Realistic Expectations:

As we all know, to help a child grow we must make it possible for him or her to experience success. It is therefore important to set expectations for children that they can realistically achieve. This of course requires attention to what we just talked about in terms of “knowing the child”. It also means that at times of stress, the caregiver must lower the bar. What a child is capable of in times of stress is different from what he or she is capable of when calm and comfortable. None of these points are unfamiliar, but caregivers often lose track of them when dealing with children.

Caregivers must also be prepared to help the child over the rough spots and to support the child’s initiative. This is more complicated than it seems at first glance. That is because when to help and when to encourage the child to try it on his or her own is not always clear. Complicating the matter is the fact that caregivers fall into patterns with children, patterns that are shaped in part by (usually out of awareness) the caregiver’s needs or by other demands of the environment. Examples include when the caregiver’s need to get ready to go to work in the morning makes it easier to dress the child than to help him dress himself. Or, the caregiver’s desire to hold the child close as she did when he was a baby in order to preserve a sense of intimacy that is no longer appropriate.

Another pattern is that of insisting a child “do it himself”, when the child actually needs some support in carrying through on the task. Examples of this situation are when the child has problems organizing the complex motor activities required in getting dressed, or when the child has problems maintaining his focus of attention. Even when the caregiver has repeated a pattern with a child frequently without success, it is hard for him or her to recognize that this way of doing things is not effective. This is especially true if the child is “hard to read”, or has a complicated mix of competencies so that he or she is very good at some things and surprisingly not good at others, such as is the case of children with uneven development. (Remember that traumatized children almost always have some degree of unevenness in development.) In these cases, it is excellent to have other caregivers offer their perspectives on the capabilities of the child. These alternative perspectives, whether offered by other caregivers in the home or by teachers, are valuable and should always be taken into account.

Finally, it is important to listen to the child. By “listen” I mean observe as well as listen to what he tells you. If the child continues to struggle, it is time to ask him what he needs to accomplish the task. Does he need your help? What kind of help? If he claims that he needs your help but that claim is at odds with your observation, you might continue the discussion – “Help me understand how you need my help to do X when I see you do it so well yourself at Y other times.” Or, “Let me watch you try it so that we can see where things go off track.” Or, “Would you have the same comforting feeling if you did this yourself and afterwards I gave you a hug?” Discussions such as these not only help the child with the task, but they also support the child’s initiative in that they encourage the child to look within and assess his own capabilities, which is a competence in itself. It also demonstrates to the child that the caregiver has an open mind, is willing to be wrong, can talk about these conflicts with the hope of resolution.

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“A Healing Place”: Part I

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I am in El Salvador and am reporting on a recent workshop I gave at the children’s home, Love and Hope, with my colleague and team member, Susana Fragano. Before my departure for El Salvador, I asked Rachel, in one of our regular skypes, what she and the tias and tios (caregivers) would like to have as the focus of the workshop. She said that what they really needed help with was how to manage severe behavior problems. She told me about some of the tantrums, insolence and noncompliance, and sexual behavior, of the children in the home. This behavior has gotten worse in the last year or so since LEPINA, the Salvadoran law that requires institutionalized children to be reunited with their biological families, has been implemented, causing most of the children in the home to be returned to their families in the community. These reunited children, when they return to the home at the request of their families – either for weekend visits or for longer stays – because the families declare themselves unable to care for them – demonstrate more problematic behavior than before the reunification. Whether the worsening in behavior is due to neglect and abuse the children report they have experienced during the time they were living with their families, whether it is a consequence of the disruption of a secure caregiving environment and the traumatic loss of the caring relationships they had enjoyed at the home, or whether it is simply due to their growing older, is not known.

In the next several blog postings I am going to report on my experiences at the home during this visit and the workshop we gave to the caregivers. For a reason that will become clear as I continue, I will call these postings, “A Healing Place”. I have awakened early to write, and as I open the curtains in the window of my favorite hotel in San Salvador, I look out on dark mountains in the near distance, palm trees and other tropical vegetation in the nearer distance, and the “Mister Donut” sign that protrudes above the rooftops and guides us home after a day’s work.

Pathway to Trouble

I introduced the workshop with a review of the sources of the problems that these troubled children now have. I reminded them of the important factors I have spoken to them about many times before: (1) Prenatal stress; (2) Early abuse and neglect; (3) A genetic contribution; (4) and the ongoing trouble caused by the effect of chronic stress on the developing brain. The more you repeat a problem behavior, the better your brain learns to repeat it. I would like to state at the beginning of this series of posts that many of the points I am making about traumatized children are equally valid in relation to children with serious developmental disturbances, such children on the autistic spectrum. That is because for these children ordinary life experiences with other people, even caring attention, can feel traumatizing.

Interrupting that Pathway to Trouble

This is what the stated goal of the children’s homes has always been. Put another way, it is “breaking the cycle” of the consequences of severe neglect and abuse. But this is very hard to do. It is also hard for caregivers to remember, to keep in mind, that the children they take care of have a story about pain and neglect in their brains. They carry it always, and it can emerge unpredictably in response to current experience. This story will not go away with good care. But it can become increasingly less potent, as a new story is created to take its place. The new story is about acceptance, trust, love, and hope. The new story is about healing.

A Healing Place

I then told them about an 8-year old girl I had observed the day before. Let’s call her “Angela”, not her real name. She entered the home at 3-years old as the victim of severe neglect and abuse, including sexual abuse. After 4 years in the home, she was “reunited” with her family. (It is important to remember that this ill-conceived law, LEPINA, was implemented abruptly, without adequate assessment of the families’ competence as caregivers, and without support for these families in the community.) When in Angela’s case the neglect and abuse began again, her family returned her to Love and Hope, with occasional weekend visits to her family. The day before yesterday, after a recent visit Angela made to her family, we observed her playing. She explained that she was making a “botiquin”. Neither Susana nor I understood the reference, so Susana asked her what a botiquin was. She explained that a botiquin was something that contained whatever you needed to make yourself better when you were hurt. With Rachel’s help, she carefully organized the contents she planned to put into the box when it was completed – band aids, tape, pretend thermometer, etc. Another girl in the home offered to help her with the project and was taping clean white paper onto the cardboard box with all the care of wrapping a present. As I watched this hurt child happily engaged in pretend play with the support of her primary caregiver and her friend, I thought to myself that she was representing in play the safety and comfort of Love and Hope. She was creating for herself a healing place.

Read this blog in Spanish.

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 II: Sally Rogers on Autism Spectrum Disorders

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Although autism is a disorder of infancy, it is not usually diagnosed until between 3 and 4 years. In a recent consortium study, 664 infants who were sibs of ASD children were followed monthly from 6 mos. to 36 mos., when they were assessed for ASD (Ozonoff et al, 2011). There were no concerns at 6 mos. At 9 mos., 6 of the 26 children who ended up with the diagnosis of autism raised some concerns. At 12 mos., half raised concerns, but one raised concerns about autism. At 18 mos. only half of the children showed signs of autism. At 24 mos., there were more, but only by 36 mos. do all the children look autistic. Early symptoms in a 12-month old: (1) Problems with imitation;(2) Repetitive behavior; (3) Abnormal play patterns; (4) Communication disorders; (5) Problems with social orienting, attention, engagement, and initiation.

Dr. Rogers showed a video to demonstrate the core diagnostic symptoms. In the video the little girl showed no gaze shifting; she was locked into stimuli. She was tracking well, transferring well from one hand to the next, and her fine motor skills seemed normal for age, but she had little finger movements that looked like repetitive movements. She shifted her gaze nicely from one toy to another but not to the person, the researcher. When she was offered a baby doll, she inspected it, moves it in space, but did not mouth it. When the researcher called her name, she did not look at her. Instead, she watched the lights and shadows. The researcher tried to play peek a boo with her and although the child first looked up at her, the child quickly shifted her gaze to the light, and then started to cry. Her parents worked very hard with her and she received intensive therapy. She is now at normal levels in speech and everything else including pretend play and initiation, except for gross motor, at 2 years.

What are the Underlying Neurological Problems in ASD? The social brain networks are different in children with ASD (Dawson et al, 2004, 2005). Impairment in the neural social reward circuitry leads to a lack of salience to social rewards, creating a deficit in social approach and orientation. Because these children are biologically not getting as much reward back from social engagement, they do not discriminate and look for it, and the baby provides fewer attentive moments to parents in that way affecting the caregiving relationship. So the child does not adequately engage in social learning and experiences social deprivation, which alters the future course of neural and psychological development. Parents adapt both by protecting the child and also by not intruding in a way that the infant finds aversive. The are “reading the baby’s cues. Rogers says that autism functions like a “Gardol Shield”, an invisible protective shield that protects the child from distressing intrusion but also continues the social deprivation. In effect, by not intervening early and helping parents change the way they behave with their children, we may be contributing to the creation of brain differences. The data is clear that autistic people are good learners throughout their lifetime when provided with educational experiences, but the early social learning in the infant and toddler period is critical.

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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 (https://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.

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Photograph by Ginger Gregory

Making Music with Your Baby

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On vacation, I have a chance to relax in the beautiful countryside and reflect. I have been reading more about the child-caregiver relationship and consideringdifferent “takes” on what makes it work and not work so well.

One of the interesting researchers I have been reading is Colwyn Trevarthen. He writes that the newborn expresses his intentions to connect with his caregiver in rhythmic movements. The body movements of the infant communicate the intention to “tell a story” with the caregiver, and have a quality of “musicality” in their rhythmicity. I remember seeing Trevarthen present a film of a father holding his impossibly small premature baby, while he sang to him. The baby’s tiny foot made up and down movements rhythmically, in time with his father’s singing.

Trevarthen says that babies are born with the capacity and the intention to make meaningful connections with their caregivers and that these connections are made through purposeful, musical body movements, generated by the lower part of their brains, not their thinking brains. Babies are very sensitive to the contingency of the responses of the caregiver to their own movements and also sensitive to ways of complementing the movements of their caregivers.

One of the observations Trevarthen made that stimulated my thinking was that most of the time the babies were the leaders in the exchange with their caregivers, and the mothers were following. Much of the periodicity in the exchange between caregiver and infant originates from the infant. Infants anticipate cooperative and positive responses to the behaviors that they direct towards their caregivers, and they are very sensitive to surprises. Experiments in which the mother’s responses were deliberately made non-contingent, such as an experiment by Murray in which she played the image of the mother on film to her 2-month old baby just a minute later, so that what the mother was doing in response to the baby was just a little off, demonstrated how sensitive the infants were to the contradiction to their expectations of how their mothers would behave towards them. The babies reacted with distress and withdrawal. Of course, mothers are equally sensitive, on a non-conscious level, to non-contingent responses her baby makes to her.

That got me to wonder about the experience of the mother of an infant who is unable to join with her to create that “communicative musicality”, especially if the mother’s reactions are out of her awareness and so she cannot make sense of them. She is likely to perceive herself as doing something wrong and not understand what that is, not understand what she should be doing differently. There are many infants who may have difficulty in creating expressive movements and coordinating them with their mothers. In ASD, we know that there are different neurobiological problems that interfere with the development of the social brain. The neural circuits mediating language and behavioral flexibility do not function normally in ASD children.

Since an early theory of language development by behavioral psychologist Karl Lashley (1951), now supported by some current studies, postulates that language emerges from serial ordering of movements, and since developmental researchers have also described the synchronous coordination of purposeful rhythms as the basis for the development of communication, it seems likely that at least some children who are later diagnosed with ASD – and also some other children with neurodevelopmental disorders – would initially have disturbed expressive movements in infancy. This could be expected to have an important impact on the mother. The more we learn about early development, the more we will be able to support caregivers in making a connection with their challenging babies.

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