General Overview:
1 – These are developmental disorders of brain function with a broad range of behavioral
consequences and severity that as a group are referred to as “pervasive developmental disorder”.
2 – While these disorders may manifest in infancy as impaired attachment, they are more often identified
in toddlers, mostly boys, from 18 to 30 months. They display either an absence or delay of speech
development and a lack of normal interest in others, or a regression of early speech and sociability occurs.
3 – The autistic traits persist in adulthood with a wide range of outcomes, from little speech and poor daily
living skills throughout life, to achievement of college degrees and independent living.
4 – The main symptoms of autism are deficits in: (1) sociability, (2) reciprocal verbal and non-verbal
communication, (3) and the range of the child’s interests and activities
– they may be affectionate, but on their terms without the expected joy and reciprocity (note: parents may
take it as independence and be proud of the child’s supposed “self-sufficiency”)
– in adolescence, the inordinate shyness, fearfulness, anxiety, or lability of mood seen in childhood may be
replaced with detachment or depression
5 – At least in very young, comprehension and communicative use of speech and gesture are always deficient
– verbal auditory agnosia (word deafness) is worst outcome and child may never acquire speech
– less severe, children with a mixed receptive-expressive disorder have better comprehension than expression (which is impoverished, poorly articulated, agrammatical, and sparse in speech)
– some who speak late may progress rapidly from silence or jargon to fluent, clear, well formed sentences
but their speech may be literal, repetitive, and noncommunicative, often marked by striking echolalia or
“overlearned scripts”, some speak nonstop to no one in particular in high-pitched singsong, or poorly
modulated voice and perseverate on favorite topics
6 – These children do not know how to play (e.g. the toys do not represent anything, there is no “pretend” in the activity which starts in normal children before age two), i.e. no symbolic thought developing
– therefore, what a preschool age child does with toys is an effective diagnostic tool to detect autistic traits
7 – Some autistic children have unusually long attention spans during self initiated activity (?= extreme
omnipotent self-sufficiency) although they are virtually incapable of focusing on a joint endeavor with
another person
– they often have temper tantrums if made to switch activities or if ritual behavior is interrupted
– inability to concentrate, combined with intrusive stereotypies (e.g. hand flapping) may prevent children
from engaging in meaningful activity or social interaction
– decreased need for sleep or frequent awakenings are very difficult for care givers
8 – Approximately 75 % of persons with autism are mentally retarded, in proportion to severity of autism
– effective treatment programs may improve this dramatically
– usually have an uneven cognitive profile with nonverbal skills generally superior to verbal skills
(although the reverse may be true in Asperger’s syndrome)
– poor insight into what others are thinking persists throughout life, creativity is usually limited
– a small minority may have surprisingly good musical, mathematical, or visual-spatial abilities despite
profound deficits in other domains (e.g. when these abilities are astounding = called “savants”)
9 – There is no known neurologic substrate (i.e. no known neurologic cause) but one commonly sees increased joint laxity and hypotonia, clumsiness, apraxia, and toe walking in small children
– motor stereotypies are often striking including hand flapping, pacing, spinning, running in circles, twirling
a string, tearing paper, drumming, and flipping light switches, as well as oral stereotypies liking humming,
incessant questioning, any of which may persist into adulthood in unobtrusive miniaturized form
– self injurious behavior such as biting, head banging, and gouging may be extreme forms of stereotypies
– paradoxical and extreme reactions to sensory stimuli, e.g. hypersensitive or oblivious to certain sounds,
smells, tactile stimuli, or pain, dislike of certain tastes or textures or food
– visual perception is usually superior to auditory, may cover their ears, stare with fascination at some
visual displays, and have outstanding rote visual or auditory memory
10 – By adulthood, about 1/3 of persons with autism have had at least two unprovoked epileptic seizures
– about 1/3 of parents with autistic children report regression of their child’s language, social, and play
skills, most often before the age of two, followed by a prolonged plateau and eventual improvement,
but not full recovery
– “Disintegrative Disorder” is a severe regression with poor prognosis seen in about 10% of children with
diagnosis of autism and is associated with EEG abnormalities and seizures (Landau-Kleffner syndrome)
11 – Note: As a group, babies later diagnosed with autism are found to have had more complications with
gestation and delivery than normal sibs, etc. and twofold increase rate of residence in neonatal ICU’s
The Spectrum of Autism – Pervasive Developmental Disorder:
1 – Autistic Disorder (i.e. classic autism) involves severe qualitative deficits in all three of the following
behavioral domains:
– social interaction
– language, communication and play
– deficits manifested as stereotypies, perseveration, and a narrow range of interests and activities
2 – Asperger’s syndrome is the disorder in non-retarded, often clumsy children without speech delay who
have deficient sociability and a narrow range of interests
3 – “Pervasive developmental disorder, not otherwise specified” is the disorder in children with autistic
behavior who do not fulfill the criteria for any of the other disorders on the spectrum
4 – Disintegrative disorder (Heller’s syndrome) is the disorder in previously completely normal children
who undergo a massive regression between the ages of 2 and 10 years, resulting in severe acquired
autism, usually with loss of cognitive skills. By definition, it does not occur in the context of a degenerative
disease of the brain or schizophrenia
5 – Rett’s disorder is a specific disorder limited to girls with acquired microcephaly, infantile regression, lack of hand use, striking stereotypic hand movements, severe retardation, and other neurologic problems
Criteria for Autistic Disorder (a total of 6 or more manifestations from 1, 2, and 3 below):
1 – Qualitative impairment of social interaction (at least two manifestations)
a – marked impairment in the use of multiple types of nonverbal behavior such as eye-to-eye gaze,
facial expression, body postures, and gestures to regulate social interactions
b – failure to develop peer relationships appropriate to developmental level
c – lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g. by
lack of showing, bringing, or pointing out objects of interest)
d – lack of social and emotional reciprocity
2 – Qualitative impairment of communication (at least one manifestation)
a – delay in, or lack of, development of spoken language (not accompanied by an attempt to compensate
through alternative modes of communication such as gestures or mime)
b – in individuals with adequate speech, marked impairment in the ability to initiate or sustain a
conversation with others
c – stereotyped and repetitive use of language or idiosyncratic language
d – lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental
level
3 – Restrictive and stereotyped patterns of behavior, interests, and activities (at least one behavior
manifestation)
a – encompassing preoccupation with one or more restricted, repetitive, and stereotyped patterns of
interest that is abnormal either in intensity or focus
b – apparently inflexible adherence to specific, nonfunctional routines or rituals
c – stereotyped and repetitive motor mannerisms (e.g. hand and finger flapping or twisting, or complex
whole body movements)
d – persistent preoccupation with parts of objects
4 – Delays or abnormal functioning, with onset before the age of 3 years, in at least one of the following areas (and a determination that Rett’s disorder or Childhood Disintegrative Disorder does not account better for the observed symptoms)
a – social interaction
b – language as used in social communication
c – symbolic and imaginative play
Communication Deficits in Autism:
1 – Phonology (speech sounds): Impaired reception and expression in children with mixed receptive-expressive syndrome and, especially, with severe verbal and auditory agnosia (word deafness) in which phonologic decoding may be so compromised as to preclude speech comprehension and verbal expression
2 – Prosody (rhythm and melody of speech): In children with speech: singsong or rising intonation, high pitched voice, or monotonous, “robotic speech” speech
3 – Syntax (grammar and word order): Impaired reception and expression in all children with autism, e.g.
impaired comprehension of questions, open-ended questions, and non-literal language such as irony,
sarcasm, and jokes; word-retrieval problems; and unusual pedantic word choices; echolalia; difficulty
formulating coherent discourse; narrow range of topics
4 – Pragmatics (communicative and conversational use of language): Impaired reception and expression in allpersons with autism, e.g.impaired interpretation of tone of voice, body posture, and facial expression; gaze avoidance; failure to answer; speaking to no one in particular; failure to initiate, pursue, or terminate a conversation; difficulty with taking turns; poor maintainance of topic; perseveration and ceaseless questioning
The Problem and/or Difficulty with Causal Explanations for Autism:
1 – Genetic predispositions are not for a particular illness, they are more for styles of responding to the
experiences of being alive and having a mind that can experience stimuli, including such emotional pains
as separation, envy, jealousy, worry about mother’s welfare, guilty concern that one is harming her, etc.
2 – Mother’s naturally feel blamed and unbearable guilt if their infant is distressed or injured in response to
the relationship with her [Kanner’s “refrigerator mothers” didn’t help!]
3 – It is very difficult to see psychological explanations that involve unconscious phantasy and attribute such thoughts to such an early period of development
– models of infantile thought (and unconscious phantasies) are needed that are beyond common sense and not well known outside of Kleinian circles of training
– understanding one’s own baby core is unavailable to most and a threat to many, and requires a lot of
analysis in oneself (and exposure to infants, to see it in others, if one has not seen it in oneself first)
Possible Genetic Predispositions:
1 – Research will no doubt uncover neuro-anatomical and neuro-physiological underpinnings that are
predisposing to developmental delays and autism, etc.
2 – Monozygotic twins have a 90% concordance for the diagnosis (not the severity), while only 5 to 10%
of dyzygotic twins of the same sex are concordant
3 – In the meantime, we can observe emotional traits and tendencies in parents and siblings that give
hints of the biological substrates that may be passed on genetically
e.g. parents might be more likely to be obsessional, less “psychologically minded” about own emotions,
more concrete in thinking, more prone to abstraction in representing emotions (e.g. mathematical or
musical in expressions of emotional states), more anxiously attached to their infants, more depressed,
more of a sensuous nature, etc.
The Role of Mirror Neurons in Development:
1 – Discovered by Giaccamo Rizzolati in the ventral motor area of the frontal lobes of Macac monkeys, mirror neurons are single cells that will fire when a monkey performs a single highly specific action with its hand (e.g. pulling, pushing, tugging, grasping, picking up and putting a peanut in the mouth, etc.) and different specific neurons will fire in response to different actions. But instead of just being muscle command neurons, any given neuron will also fire when the monkey in question observes another monkey (or even the experimenter) performing the exact same action.
– These neurons help humans have mind reading empathy, imitation learning, and even the evolution of
language. In effect they help one read and understand another’s intentions. The loss or failure to develop
these neurons may be a significant aspect of the development of autism.
– mirror neurons enable the infant to mime its mother sticking out her tongue and may aid in the evolution of language development, i.e. by ability to read someone’s intentions and ability to mime their vocalizations
– “anosognosia” or “denial syndrome” = a disorder seen in 5 % of patients with right hemisphere strokes who have a complete paralysis of their left side, but who instead of complaining about the paralysis, deny that it exists even though they are otherwise lucid and intelligent. The amazing part is that some also deny the paralysis of another patient! This may be explained by damage to their mirror neurons and may imply that to make a judgement about someone else’s movements you have to run a virtual simulation of the corresponding movements in your own brain using your mirror neurons.
– The human evolutionary development of mirror neurons may have lead to the explosion of cultural
innovations that make us uniquely human. If something was invented accidentally in one place, including
such things as tool use, shelters, tailored clothing, art, speech, writing, math, etc., the mirror neurons would contribute to the proliferation and spread to other places because of the capacity for imitative learning and mind reading. [Note: This contributed to the rapid “cultural transmission of knowledge”, as seen in the last two hundred years, that is not the same as a genetic mutation leading to change and evolution.]
The Biological Causal Explanations (probably nature “via” nurture):
1 – Genes are designed to take their cues from nurture! That is genes and the environment are locked into intricate feedback loops whose interruption even in subtle ways can be disastrous for development, especially since the first year of life, like embryology, is so determinant of later development.
2 – The prevalence of autism in the population seems to range from one in 100 to one in 1000 in UK and US
[Note – Thimerisol, a preservative agent in MMR vaccine with traces of mercury in it, and a fairly strong
allergen for many people, has been removed from all vaccines for infants and children and has been
rejected as being a possible causal agent by most of the medical/scientific community]
Overview of Psychoanalytic Models for Autism and Developmental Delays:
1 – Infants have a very small repertoire of protective psychological maneuvers available to cope with mental pain and unwanted stimuli, and among them Melanie Klein emphasized:
– denial, “splitting-and-idealization”, and “splitting-and-projective identification” as the core ones used by
the infant to cope with the pains of separation, envy, jealousy, guilt, confusion, etc.
2 – These can be thought of operating on several continuums:
– how much is the infant “turning toward” its object or “turning away” to omnipotent self-sufficiency
e.g. how much is the infant trying to obtain reassurance in the absence of the object (e.g. a transitional
object) versus to what degree is the infant “doing away” with the object entirely
– to what degree do the underlying phantasies involving “getting inside” the object to essentially become
“unborn” again as a solution to life’s pains
– how much violence is involved in the unconscious phantasies, especially where envious resentment
is intense
3 – It is useful to start by thinking of autism as linked to a deep depression in the infant (and maybe mother
as well) about separation and thus many of the stereotypic behaviors as the infant “holding itself together”
– the autistic child’s reaction to birth and separateness is more of a catastrophic, primal event that is
often referred to as a “black hole” suggesting that the infant’s rage, grief, etc. are of a severity greater
than normally experienced and the emotions are more physical, and sensuous, like “an avalanche sweeping the infant away”
– not infrequently, the mom and infant cling to each other, leaving no space for cognitive and emotional
development, so that no symbol formation takes place
– these infant’s seem to have had a terrible fear of death – worse than real death – like falling into a black
hole of nothingness (e.g. sometimes seen in a fear of bathing as if skin would wash away)
– it is as if some babies feel “skinned alive” by birth, and since mom and baby both are felt to have been
wrenched apart and injured, mom can’t help and dad doesn’t have any influence that is felt
– mom is experienced as a limb of the baby’s body or a protective skin to be used, but it fails to make up
for the original loss, and stereotypic behaviors are needed continuously to cope with constant danger
Donald Meltzer’s Model for Austism:
1 – Begins with a premise that the infant perceives its mother as being injured by its needs (as might be seen in a depressed, somewhat perfectionistic mother) and so the infant tries to spare her from its needs and pain
2 – This gentler, more depressive type of sensitivity to mother is thought to lead to a unique set of maneuvers,that are less violent and intrusive, in order to spare her, by “dismantling” the sensory apparatus into its component parts so that each of the five senses is experienced separately and not integrated into a whole “organ of attention” that can accurately perceive the surround and have an emotional experience of it
3 – This dismantled “uni-sensual” approach to experience precludes the development of a three dimensional world in which to live and fails to develop a “psychic space” as a consequence, leaving only the ability to “adhere” to the surface of a two dimensional object via what he calls “adhesive identification” (in contrast to the unconscious phantasy of getting inside the object that is typical of “projective identification”)
– the failure in infancy to develop a three dimensional psychic space is catastrophic for later development
Francis Tustin’s Models for Autism:
1 – Tustin’s models tend to emphasize a turning away from the object to omnipotent, self generated and
soothing maneuvers that can substitute for the awareness of need of the mother
– her maneuvers of creating “autistic objects” and “autistic shapes” have a lot in common with the “anal-
omnipotence” seen to varying degrees in all children, healthy and disturbed
2 – “Autistic objects” are hard in their sensory aspect so that they generate tactile sensations on the surface of the skin or mucous membranes giving one a primitive sense of security, durability, strength without any time-space awareness [think of the skin as the largest sensory organ, and perhaps the first]
3 – “Autistic shapes”, by contrast, are soft tactile, sensory experiences that are soothing and comforting, in
effect anaesthetizing, random on bodily surfaces but also not conceptualized, so not anything that would
lead to awareness of an object that one needed
e.g. the shape one’s rear end in a chair is felt rather than the chair being felt
e.g. in contrast, Winnicott’s “transitional object” is linked toward an object symbolically in its absence
4 – The infant ends up in either an “encapsulated autistic state” in a two dimensional world of its own creation, maintained by its own idiosyncratically generated universe of stereotypies that hold it together; or “confused autistic state” in which the child has “melted into and become entangled” with outside objects. The latter are harder to treat because the parents have more confusion and enmeshment in their own states of mind.
Signs in First Six Months of Infants Later Diagnosed as Autistic [though not unique to Autism]:
– Flaccid body tone, lack of responsiveness or attentiveness to people or things, lack of excitement
in presence of parents, lack of anticipatory posturing on being picked up, vacant or unfocused gaze,
less than normal activity (e.g. reaching for objects), specific motor deviations (e.g. head lag on being
pulled to sitting or facial palsy, ptosis = eye lid droop), eye squint mannerism, predominantly irritable
mood and little smiling, more somnolent than typical child
First Symptoms of Autism, Typically Six to Twelve Months:
– Seeming hallucinatory excitement, appearance of self-absorption, no visual pursuit of people, repeatedly
looking away from people, avoiding mother’s gaze, resisting being held or arching torso away from the
parents, autisms/stereotypies/motor mannerisms including: hand flapping – finger dancing movements –
rocking – spinning, plastic expressions that do not communicate affect or intention, labile facial expressions
that shift form grimaces to squints, fragmented and uncoordinated body movements, episodes of flailing and aimless un-modulated activity
Symptoms of Established Autism, Typically Twelve to Twenty Four Months:
– Child doesn’t approach parents, child keeps distance from parents, constricted – flattened affect,
little or no purposeful activity, facial expression that doesn’t convey intention or meaning, failure
to normal language development
Treatment of Family Situations with a Developmentally Delayed Child:
1 – The earlier the intervention, the greater the chance of getting more of development back on track
– although a diagnosis of autism is usually not made until language has failed to develop (thus when the
the child is age 3 or 4), 50% of parents report they suspected a problem before their child was one year
– overwhelming guilt in parents, esp. moms, has to be addressed early and continuously
2 – The child has fundamental defect in their motive for engagement with the world that will seriously alter
its development of imagination and expressive capacity for interpersonal contact, and parents will
ultimately cease to expect or wait for a reciprocal response to engagement (= vicious cycle)
3 – Infant-parent psychotherapy that is psychoanalytically informed seems to be proving the most useful
in treating the “non-talker” infants because the array of models seen in psychoanalysis is helpful in
aiding and supporting mothers who sense something is wrong with their infants
4 – The greatest successes seem to be with very intensive treatments involving the parents and the child in multiple modalities that prevent the child from remaining encapsulated in its own world while simultaneously aiding mom in seeing meaning in the child’s behavior and thus feeling empowered with techniques for acting upon her insights
5 – Eight common elements in successful treatment of autism:
(1) – Rx begins with an effective theory of how the affected child’s mind is functioning and not functioning
(2) – parents have a strong sense of autonomy, efficacy, mission, and sacrifice (or professionals must help gain)
(3) – treatment requires continuous engagement with the child
(4) – successful treatment is a team effort
(5) – there must be a drive to normalize the child, treat like other children in family or community
(6) – successful treatment finds and builds on a positive element in the child’s characteristics
(7) – treatment began early in life, by age 4, (i.e. 6 months to 4 yrs) when massive reorganization of CNS
connections is still possible in a positive direction instead of a negative direction
(8) – children with positive outcomes were not retarded (i.e. some signs of normal intelligence before Rx)
Useful Kleinian Oriented Bibliography:
Donald Meltzer, “Sexual States of Mind”, Clunie Press, 1973
[This is my favorite PSA book in the whole world! It is a tough read, very dense and terse but it covers a huge amount of normal and pathological development from a Kleinian perspective. Its chapter on “fetishistic playthings” includes a brief overview of ‘dismantling” that helps differentiate autistic from psychotic states. No practicing mental health professional should be without this book, especially if you see adolescents.]
Donald Meltzer, et. al., “Explorations in Autism – A Psycho-Analytical Study”, Clunie Press, 1972
[This book has chapters written by Meltzer and by his four co-authors who are treating the individual case
examples, whose psychoanalyses are detailed in the book. These are very sophisticated Kleinian treatments that will give the reader a good overview of minute dissection of the unconscious phantasies in autistic kids. If you are serious about working with autistics, this book is a must own.]
Frances Tustin, “Autistic States in Children”, Routledge and Kegan Paul, 1981
[Tustin, who was analyzed by Wilfred Bion and worked with many of the London Kleinians and Winnicott,
devoted her life to working with autistic children. Her theoretical models and case write-ups are really useful to anyone interested in working with autistic/psychotic children and their families. This book nicely overviews her ideas on autism and is compatible with her other works except that she later modified her idea of an early stage of normal autism in the first month of life (after infant psychiatry research confirmed Klein’s assumption that the infant at birth had sufficient “ego capacity” to see mom as separate and have a relationship with her.]
Frances Tustin, “Autistic Barriers in Neurotic Patients”, Karnac Books, 1986
[This book is slightly more general than the one above and may be more accessible to a reader who is less
interested in great depth about autism. It makes a broad reference to “autistic” features seen in other types of neurotic and psychotic patients. Tustin sees this book as emphasizing the “barriers” to contact and development aspect of autism.]
Frances Tustin, “The Protective Shell in Children and Adults”, Karnac Books, 1990
[This book emphasizes the “protective” aspects of encapsulation and carries forward bits and pieces of her
thinking as it has evolved since Dan Stern’s book in 1987 on the interpersonal world of the infant (which nicely summarized a huge amount of early infant psychiatry research). This book also includes some previously unpublished papers and has several chapters on psychotherapy with autistics, and non autistics that have features in common with autistics.]
Stella Acquarone, editor, et al, “Signs of Autism in Infants – Recognition and Early Intervention”, Karnac Books, 2007
[This is an excellent compendium of internationally prominent researchers and clinicians who work with
autistic children. It is not analytic, per se, but still has an analytically informed psychotherapy type of slant
to it. It is worth owning if you are an infant development specialist or interested in such. It has some very
compelling chapters on very early recognition of potential autistic precursors.]