Barcelona 1996
Saturday 4th May, 17.15-18-15, Panel 35
Problems in early detection
There have been a number of obstacles to early recognition that a child is at risk for developing autistic behaviour:
- Uncertainty about the nature of early signs.
For many years it has been known that
a majority of children later to be autistic were rather non initiating
babies. Parents described their children as having been good
easy babies, happiest when left alone, not very cuddly, hardly
crying etc. These retrospective reports were later supported
by the work of Henry Massie (1975), then others who examined home
movies and then video records of babies later diagnosed autistic.
However far from all "good" babies become autistic.
More recently Baron Cohen and colleagues (Baron Cohen
et al, 1996) using CHAT, the Checklist for Autism in Toddlers,
worked with Health Visitors to screen 16.000 18 month olds at
the standard 18 month check all UK toddlers should have. They
found 12 toddlers who did not have "protodeclarative pointing",
"gaze monitoring" and "pretend play". 10 of
these were diagnosed autistic and this remained the diagnosis
at follow up at 3.5 years. The rate of false negatives, in other
words the number of children later to be diagnosed autistic, is
not yet known. In addition whilst 18 months is early detection
by current standards, and may be about the earliest that reliable
diagnosis can be made, there are reasons for believing that treatment
earlier might be substantially more effective.
Detecting an absence. The
problem with all these behaviours is that they describe features
about which parents rarely complain (being a "good"
baby) or which are subtle and not usually explicitly discussed
and which individually, as for example Baron Cohen et al's study
showed, are not clear risk factors for autism
- Rarity of autism and the lack of clear and accepted
early treatments and referral routes. Not
only will most community health workers rarely if ever encounter
an autistic child because of autism's rarity compared say to sleep,
attentional or behaviour problems, but also the motivation to
detect is severely diminished if there is no obvious referral
route or treatment. In other words, if early detection makes
no difference, why bother?
It is widely accepted that early treatment, and so
by necessity early detection, of autistic behaviour is desirable.
However there are differing views on how autistic behaviour develops
and on how effective early treatment is likely to be in reducing
or removing autistic behaviour.
The development of autistic behaviour
Our view, shared by many others, of the development
of autism is that autistic behaviour is the common path arrived
at via many different routes (Richer 1983). The aetiology of
autism is heterogeneous - different in different children.
It is also multiple, requiring a number of causal factors to add together. The list of possible causal influences includes
- genetic factors, as twin and family studies show,
- intra uterine events,
- the independent presence of leaming difficulties,
- various syndromes such as tuberose sclerosis, or fragile X,
- dietary intolerances and epilepsy,
- security threatening events especially at sensitive
or at transition periods.
These push the child towards autistic behaviour.
Once the autistic behaviour is established it begins to maintain
itself in normal social environments and to have adverse consequences
on the child's development, in particular the learning of social
skills such as language, gesture, empathy skills and "political"
skills within groups. (Richer, 1983, 1994)
The description of autistic behaviour
What is this autistic behaviour? Whilst the diagnostic
criteria are now widely known, and the diagnosis, at least of
the older more severely affected children seems fairly reliable,
most more detailed descriptions of autistic behaviour have been
impressionistic or have comprised a description of one or more
deficits. Whilst both are useful the former make reliable scientific
communication difficult, and the latter are usually difficult
to put together to make a coherent picture.
We have used the approach of Ethology in which clear
descriptions of publically observable behaviours are made, but
then these behaviours are clustered into motivational categories
based on their tendency to appear at the same times or in the
same causal situations.
Both the Tinbergen's (e.g. Tinbergen and Tinbergen,
1983; Richer 1975, 1983, 1991) and I have re-described the social
behaviour of autistic children in terms of motivational conflict
between strong fear (or avoidance) motivation and other motivations,
notably attachment and sociability. Some examples of fear and
sociable behaviours are:
Avoidance or fear Sociable
move away, turn away Move towards, turn towards
look away look towards / gaze fixate
hands over ears/ eyes, hang head down smile, talk, point, proffer, receive
being on the periphery, go still, fear grin
Motivational conflict behaviours are listed in Figure
1.
Name Everyday description
Exploration............................................"trying
to solve the problem"
Simultaneous conflict
(Elements of avoidance + other)............. Ambivalent, Dithering, Inattentive
Alternation in conflict..............................
Overintensity:
respond too soon, too intensely, "Impulsive and careless"
too briefly and to partial cues,................."rushing
into things"
Switch attention from activity................."Poor concentration"
"Inattention
Frustration,
Conflict
Switch attention from person......................"ignore/avoid person"
if "pressured"
Displacement activities...............................fidgit/fiddle/scratch/tics
Aggression stereotypies, etc.
Re-directed aggression..............................."taking it out on
somebody/thing else"
Regression................................................
"babyish"
Attachment behaviour.................................."seeking
comfort"
This view has been misunderstood in many quarters
on at least two counts. Firstly the nature of motivational conflict
behaviour has not been understood and inappropriate experiments
done which claim, falsely, to "disprove" the redescription
(i). Secondly, it has been thought that we were asserting a psychogenic
causation, back to "refrigerator mothers" as it were.
This misunderstanding displays a considerable naïvety about
human development; current problems in parent-child relationships
do not imply that the parent behaved somehow oddly. There are
after all difficult relationships with children with epilepsy,
or severe mental handicap or even hyperactivity? Psychosocial
problems do not necessarily have psychosocial causes.
Let me give some examples of these children's social
behaviour. The well known approaching or taking the adult's hand
but without gaze fixating, or approaching but from behind are
examples of simultaneous conflict behaviour, elements of approach
and avoidance appear together - approach or hold the adult, but
avoid gaze fixation or avoid the front of the adult. Autistic
children can sometimes be observed rushing up to, but then going
passed an adult, or approaching, dithering then going away - both
examples of the alternation of approach and avoidance. Stereotypies
are an example of displacement activities.
Quite puzzling to some people is the behaviour of
rushing up to an adult and crashing into her, or staring from
a few centimeters away, or the child burying himself into an adult's
body, or in the more intelligent, less severely affected children,
blurting out something loudly and inappropriately whilst staring
at the adult. All these are examples of overintensity, of the
child responding too soon to partial cues with too great motor
intensity and too briefly. He is impulsive and careless.
Some of us are fortunate enough to be able to see
very young avoidant children and also to see slightly older children
whose avoidant behaviour, whilst significant, is not severe (such
children are often referred for language delay or simply odd puzzling
behaviour). This experience makes it clear that, especially with
children under three there is no clear dividing line between "autistic"
and "not autistic", and that the children's behaviour
is much better and more usefully described in terms of avoidance
and motivational conflict.
There seems to be a dimension of behaviour difference,
sometimes called the autistic continuum, at one end of which is
seen strongly avoidant and stereotyped behaviour and at the other
perhaps slightly eccentric behaviour. In between is behaviour
frequently characterised by overintensity, approaching too intensely
and inappropriately, and children who show this predominantly
have been various categorised as "active but odd", "symbiotic
psychosis", "schizoid", "Asperger's",
having "severe disorders of ego development" and so
on.
In attachment theory terms, autistic children's behaviour
can be re-described as the extreme avoidant behaviour of insecurely
attached children. This has lead to extreme premature
independence to the detriment of the child's relationships
and development. Let me repeat, this says nothing about earlier
causation, when will some people stop having the knee jerk reaction
that social relationship problems, and particularly insecurity,
always have only social causes?
Immediate causal factors
What are some of the immediate causal factors affecting
avoidance? Firstly avoidance intensifies when the situation or
activity is frustrating/ uncertain/ difficult, and is less in
clear simple or well structured settings or activities. Secondly,
avoidance is least when the adult is relatively undemanding or
intrusive in their social behaviour towards the child, or when
the adult is very demanding and sustains that until the child's
avoidance substantially reduces. Ordinary friendly communicative
behaviour tends to promote avoidance. (Figure 2)
These two factors interact. The adult can be fairly
animated and sociable if what is being done with the child is
very simple, such as baby play. On the other hand when an activity
is difficult for the child, the adult needs to be much less intrusive.
HIGH
Approach Social
demand /intrusion
Avoid Easy,
predictable
activities
Difficult,
unpredictable
activities
Approach
LOW
Therapeutic approaches
This immediately implies certain therapeutic approaches
(Figure 3): animated baby play, unintrusive presentation for more
difficult activities, firmness over appropriate issues and holding
(Welch, 1983; Richer and Zappella, 1989; Richer, 1991) (which
again has been much misunderstood and which I shall return to.)
One major first goal of therapy is to improve
security of attachment between parents and child. Achieving
this releases many normal developmental processes. It is done,
in part, using these approaches.
Let me try and put each of the three approaches in
a developmental perspective.
Firstly holding. The point of holding a child
with autistic behaviour is the same as holding any child in a
temper, namely it is an insistence on comforting a child
who for as long as he had had avoidant behaviour had rarely allowed
his mother to comfort him, to the severe detriment of his security
of attachment. His insecurity has promoted his avoidant behaviour
which helped prevent his insecurity from being reduced. Holding
aims to break that vicious circle and, to put it too briefly,
help the child re-start his development from where most children
do, sufficiently securely attached to his mother and other caregivers
to begin to communicate and learn with them. At the end of some
successful holding sessions the child stares at his mother (or
father) in a way reminiscent of the stares of babies in the first
4 months
Social demand / intrusion
HIGH
Approach
Escape
from by:
Avoid Easy,
predictable
activities
Difficult,
unpredictable
activities e.g.Option (Kaufmann)
Approach Zappella
LOW
e.g. Facilitated Communication Unintrusive
(Biklen) activity-centred
play
of life. He even looks younger than his age. The pair also of engage in conversation with prolonged mutual gaze again reminiscent of this early period. Trevarthen (1980) has called this the stage of primary intersubjectivity. The pair are beginning to negotiate shared understandings
about each other.
Secondly animated baby play. The play is very
similar to that which properly gets under way in the second half
year. The parent is very animated, lots of broad smiling, gentle
but animated jolly talk, laughter and sounds, following what the
child does and perhaps elaborating on it, offering simple games,
often of the tension and release sort like pee a boo, but in no
way insisting or being pedagogical. The emphasis is on enjoyment,
having fun together, and communicating. Mothers generally find
this easier than fathers although fathers do well with rough and
tumbly 'father play'. The therapy of Professor Zappella (e.g
Zappella et al, 1992) in Italy contains this aspect. I suspect
that the methods of the Kaufman's Option Institute in Massachusetts
(e.g. Kaufman, 1976, 1991) are similar to this.
Third, quiet socially unintrusive object play.
Here the adult concentrates on setting up the situation such
that the child finds the task adequately clear, simple, interesting
and rewarding. The adult talks very little and only about the
task, leaves lots of time for the child to respond, and is like
any good parent who facilitates the child's play but does not
over intrude and distract. Where the adult joins in, she
is task oriented, not child oriented, and the relationship is
developed through jointly doing some task. With autistic children
the difficulty lies in choosing the tasks. Again this is very
similar to what good parents do with their children, especially
from about 9 months. This bears similarities to the stage Trevarthen
calls secondary intersubjectivity, when the pair are negotiating
shared understandings about the world. Facilitated Communication
(e.g Biklen, 1992) with autistic people, has the features of this
approach.
In play with babies, these last two methods are often
observed to occur together, a sensitive mother swiftly alternates
from animatedly communicating with her child to quietly supporting
her baby's observation and object play, in response to her baby's
behaviour.
The difficulty with all three methods is that these
activities need to be done with children who are older than the
babies and toddlers they are naturally done with, and with children
who often do not return the signals which sustain the adults in
these activities; indeed the children are sometimes downright
avoiding. Indeed, without understanding these approaches and
the ideas behind them, many adults naturally behave in ways which
only maintain the child's autism. The children elicit
the wrong adult behaviour at the wrong time, in particular overintrusive
approaches when the situation is uncertain, and this is one of
the many mechanisms by which avoidance is maintained.
The parents thus need to be supported and helped
back to types of parent child interactions that support ordinary
developmental processes. Just what these types of interactions
are is informed not only by what may be seen in modern societies,
but also by what is known of such interactions in Hunter-Gatherer
societies in which the bulk of human evolution took place and
to which we are genetically most adapted. Thus there is an emphasis
on avoidance of separations, lots of body contact, comforting,
grooming, playfulness, slow pace of interaction with baby and
so on. In therapy aspects like these are sometimes exaggerated
beyond what is usually found in modern societies.
The improvement stages
If parents can be supported enough and if the child
does not suffer current physiological problems or a severity of
learning difficulty that vitiate therapeutic efforts, then improvement
is seen. Not only do children lose their predominating avoidance,
but in doing so they also go through the stages that would be
predicted from increasing security and decreasing fearfulness.
What are these stages? There are three (Figure 4).
In stage 1 there is strong fear or avoidance motivation,
motivational conflict behaviour is dominated by avoidance where
simultaneous or alternating conflict are often seen.
In stage 2, fear motivation is reducing and overintensity
is frequently seen. Thus the child changes from being attention-avoiding
to excessive attention-seeking with strong separation anxiety.
This is first seen in simple baby activities, later with more
sophisticated activities including speech. As one mother said
about her daughter, "I have waited 6 years for her to speak,
now I wish she would shut up!"
In stage 3, the child's social behaviour is like
that of most other children, with ordinary reciprocity and communication.
A child's behaviour occupies a range on this dimension and as would again be expected the stage of behaviour a child shows at any one moment depends on several factors which include whom he is with, how that person is behaving, where he is, and what they is doing together.
Essentially, the more secure he is with the person,
place and activity, the more his behaviour is in stages 2 and
3.
Oxfordshire services for young children with autistic
continuum behaviour
This is the approach that informs the work in Oxfordshire.
A network of professionals has grown up comprising clinical psychologists,
preschool teacher counsellors, specialist teachers for autism,
speech therapists, audiometrists, health visitors, community paediatricians
and child psychiatrists. Children come to notice not only for
the usual reasons such as suspicion of deafness or worry about
language delay, but also because of early concern about the avoidant
quality of social behaviour amongst community workers, especially
teacher counsellors, speech therapists and audiometricians. They
are referred to the specialist clinical psychologist (JR) and
often also to the specialist autistic service within education
and to the community paediatricians. As with many networks the
referrals may be made in different ways around the network, but
soon all the relevant people are involved.
The broadening of detection criteria to include "socially avoidant" or "disoriented" (in attachment theory terms) behaviour has several advantages:
- it makes identification of children to be referred easier because it focuses on current behaviour,
- it is informed by a theory of normal development, attachment theory,
- it acknowledges that the wider group is (probably) also in need of help,
- it acknowledges what is apparent clinically with
the younger children, namely there is no clear dividing
line between autistic and non autistic children.
(i) For instance, van Engeland et al (1985) and later Buitelaar et al (1991) recorded the
behaviour of autistic and non autistic children in a single playroom (and nowhere else) and subjected their data to various statistical procedures including principal components analysis and sequence analyses. These statistics failed to reveal an "avoidance" component, and failed to shown some expected sequences. From this they concluded that these children were not avoidance motivated. This conclusion is flawed for number of reasons which include the following:
1. Any ethological study uses data from behaviour in everyday environments as well as experimental situations: they did not.
2. The description we make of autistic children's behaviour is of motivational conflict behaviour. In most situations therefore approach and avoidance behaviour will be observed together and so crude statistical analyses based on what behaviours occur together will not reveal an avoidance component, and will not reveal sequences where the children show only avoidance behaviours to certain behaviour by others.
3. They describe, as if it were contrary to
our position, studies which show gaze behaviour is dependant on
circumstances. Of course it is. 4. They describe, again as if
it were contrary, aspects of joint attention and reciprocity
that are different in autistic children, our work has not only
described that long ago (e.g. Richer 1978), but also explains
why the children should behave as they do in terms of the underlying
motivations and causal factors of the social situations.
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