Recognizing and Treating Early Signs of Autism: Applying Theory and Research (part 2)

M&R

 

Applying Theory and Research to Recognize and Treat Early Signs of Autism 

What infant interaction research can tell us about early signs of Autism

The emerging research on Autism, infant development and infant – parent interaction provide direction regarding where to look for the first challenges to the relationship and the earliest symptoms of Autism we could observe in common infant-parent interaction patterns.

Autism Research:

Researchers in the field of Autism are to beginning acknowledge the value of looking at the elements of early social interaction as clues to developing effective interventions for young children with Autism. Most of the research has focused on joint attention and imitation in toddlers, (Schreibman, et. al. 2015). Theoretical models have proposed that the intrinsic risks or vulnerabilities in infants may be amplified by failures in infant- parent interaction patterns in the first months of life, and point to the positive implications for intervention that emerge from this dynamic view of development (Dawson (2008); Wallace and Rogers (2010 ); Elsabbagh and Johnson (2010) ; Green, et al (2013)). Reciprocity, joint attention, and mutual engagement have been identified in the literature as important markers of early social interaction and communication that are dependent upon the nurturing factors in the social environment (NICHD (2000); Murray, et al (1996); Kasari et al. (2010)).

Sensitive parental responses are identified as an important supportive element in the child’s later development of joint attention and communication. Parental sensitivity is defined as the adult’s ability to follow child- initiated and child-focused topics for joint attention (McCathren et al 1995; Harris et al 1996). This may be particularly important in children whose developmental impairments lead to difficulties in accommodating demands to shift focus and to regulate several competing demands on attention (Legerstee et al. 2002 ; Yoder and Warren 2004 ; Walden et al. 1997 ). However, it is just these hard to reach babies that can elicit increased parental directiveness, and reduced attention to the infant’s signals, affect and liveliness. When these characteristics of interaction were measured at 8 months in a cohort of infants at high familial risk for Autism, they led to reduced dyadic mutuality, infant attentiveness and infant positive affect at 12 months, and were predictive of ASD outcome at 3 years (Wan et al 2012 a, b).

These findings are consistent with retrospective study of parents’ home videos suggesting that specific directive behaviors (longer stimulatory behavior, and more use of touch to elicit attention) differentiated parents whose infants were later diagnosed with ASD (n =15) from parents of typically developing infants and infants with intellectual disabilities (Saint-Georges et al. 2011 ). Interventions that result in child initiation, exploration, and ongoing engagement with the social as well as the physical world are likely to lead to greater child learning long term, and these self-initiated learning behaviors need to be identified as treatment goals and examined when assessing children’s response to treatment (Rogers and Vismara, 2008). According to Schreibman, et. al. (2015) Autism researchers are in agreement about the need for naturalistic interventions.

” While studies to date provide considerable empirical support for the effectiveness of naturalistic interventions, there is a need for procedures, to test the long -term effects of the procedures, and to increase the efficiency and effectiveness of naturalistic interventions . In particular, larger scale research studies are needed that include measures of meaningful, functional outcomes across contexts and over time and which examine the range of child responses to treatment. “

Let’s turn to the developmental and psychodynamic research on interactional synchrony to delve deeper into the suggestion that child initiation, infant attentiveness, and affective vitality in the relationship are the variables we should attend to in research, and may help us to formulate our earliest and most successful interventions. Where do initiative, attentiveness and affective vitality and cueing originate? As we examine the research on interactive synchrony in the infant – parent dyad, we will see how these aspects of development emerge from birth in a context of warm, well-attuned interaction and co-regulation, and unfold over time to endow the infant with capacities for initiation, self-regulation, and a sense of agency in the world.

Early capacities of infants

 Development of gaze regulation

Unlike early conceptions of the infant as merged or undifferentiated from  the mother,  modern developmental research reveals autonomous, well- differentiated functioning emerging much earlier in development. Between 3-5 months of age babies take control over initiating and terminating moments of direct visual engagement in social activities  (Stern, 1971; Beebe and Stern, 1977). Although the infant is not walking or talking, or even sitting up, control over gaze is a mature sensory system and a powerful form of social communication. The baby shares almost equal capacity to regulate the same social behavior  as the parent. The infant initiates, terminates, sustains and avoids social contact through the co-regulation of gaze. Eye contact, or gaze avoidance is perhaps the most frequently noted symptom in children with Autism. One can imagine how a 3 month old would use his early control over gaze as self- protection from overstimulation via other sensory modalities, sending a signal to the parent to back off or look away as well. Observation of face -to -face interaction in these early months could help circumvent a routine pattern of avoidance establishing itself in the system of dyadic interactions.

Mutual regulation

Research on the emergence of mutual regulation and shared experience between parents and infants provides information needed to take a more interpersonal look at the early signs of Autism. Brazelton (Brazelton, Koslowski and Main, 1974) describes a narrative cycle between the newborn and parent that includes initiation by infant or parent, visual orientation to voice, acceleration of intensity of expression, a peak of excitement and deceleration process. Trevarthen ( 2005) describes an interaction cycle that begins with mutual attention and quickly moves to anticipation, change in emotional arousal and change in exchanged expressions of enjoyment.   A sympathetic regulation of arousal via communication of emotional state is necessary for anticipation to occur. Emotions are the conduit for how we regulate arousal and create internal models for how we expect others to interact with us. Over time, through this system of interaction, the infant develops an anticipation of how interactions will  proceed leading to how it feels to be me interacting with you, and eventually, moments of anticipation generalize to the baby’s expectations about interactions with others in the baby’s life.

Affect attunement

There is choreography between newborn and parent with a rhythmicity and mutuality in moments of shared recognition. Stern (2010) describes the dynamic nonverbal elements of interaction that bring infant and parent together for a matching of inner states that create moments of meeting. Temporal elements such as the flow of an interaction, the tempo, slowing down or speeding up with vocal tone or gesture are the earliest forms of communication. Through affect attunement, (Stern,1985) a sensory- motor affective cross modal parental gesture that matches the vitality affect of the infant, the parent shows the baby that she understands what it felt like to do what the child did. The simultaneous realization of a shared experience joins the infant and parent in a mutually gratifying relationship. There is an important difference between parents’ direct imitation of the baby’s behavior and affect attunement. Rogers and colleagues have initiated a pilot study of infant autism intervention focused on parent training beginning at 7 months (Rogers, et al 2014.) The parents in this study were taught to imitate the baby’s sounds and actions. In comparison, affect attunement creates intimate connection through shared affective states. The parent does not show the baby what he did, she lets him know she can feel what it is like to be him.

 

The difference between attunement and imitation

In the following video you can see the therapeutic difference between direct imitation and affect attunement. Notice the absence and presence of affective connection between the baby and his father when the father simply imitates the baby’s movement pattern, and when he becomes affectively attuned with the baby’s emotional experience of rolling the drum. Through attunement, parent and infant meet through gaze and shared brightening of expression in the eyes and mouth that give the observer a clear indicator that shared interpersonal experience has occurred.

 

Creating moments of attunement in a sensitive system

The failure of parent and infant to find each other in shared experience creates a different dynamic system, characterized by physical withdrawal, shutting down of sensory seeking through gaze, flight and freeze responses in the motor system, and dis-coordination of rhythmicity in motor and vocal activity.

Finding each other  

The following example illustrates the process of mutual regulation unfolding between a ten-month-old girl and her mother following a session during which the parents confessed that they felt Mary was only happy when she was left alone. Tearfully, the mother bemoaned that all mothers want their children to be happy. The therapist reassured them that the infant’s happiness is meant to include her parents, and the work they would embark on together would be focused on making that true. The following vignette describes the process of helping Mary and her mom find a moment of meeting during a therapy session several weeks later.

Mary is sitting on the rug holding a blanket with the mother and therapist seated on the rug nearby. In earlier sessions we have learned that Mary is more likely to respond to Mom’s initiation of mutual gaze when the mother is seated 3-4 feet from Mary rather than holding her or appearing in close proximity. Mary’s over arousal with too close physical contact or too many sources of sensory input, and her subsequent retreat are difficult to understand given the typical infant’s pleasure in being held and looked at.   The presence of the therapist holds the mother’s anxiety that Mary will terminate gaze and withdraw, happier to be on her own. As the mother has learned from discussion during other sessions, she must move slowly to invite Mary into closer contact. She either moves or talks, offering only one source of sensory information at a time, in a temporal sequence Mary might absorb. By moving closer to Mary in very small increments of space, Mom is able to sustain their mutual pleasure in gazing at each other. Mom picks up the blanket Mary has dropped and puts it in front of her own face. She initiates a peek-a-boo game with Mary, who brightens and chortles with pleasure when Mom reappears. The therapist softly coaches Mom to go slow, repeat the peek-a-boo, give Mary time to adapt to the game, then come a little closer to her daughter, and a little closer, very slowly. After painstakingly moving toward her daughter she is finally just in front of her with the blanket hiding her face. The just right pace of the game keeps Mary engaged and then activates her motor system to take initiative and expand the interaction. Mary reaches toward the blanket and pulls it off her mother’s head with a big chuckle and a broad smile, reveling in her sense of agency and capacity to initiate, reciprocate, and co-construct their shared experience.

Mary’s mother is overjoyed with her daughter’s sustained shared attention and responds with well- calibrated pleasure to Mary’s initiation. This exchange is a new experience for mother and child. Mary is neither the passive recipient nor the overwhelmed avoidant responder to her mother’s invitations for interaction and emotional connection. Her mother’s supported capacity to meet her in just the right rhythm with just the right approach in space and intensity of affect enable Mary to become a co-creator of her experience, mobilizing her motor system and energizing her positive affective response.

Intersubjectivity

Trevarthen’s (1998) conceptualization of the development of intersubjectivity is based on the synchrony of movement and vocalization between the infant and the caregiver. Condon and Sander (1974) first demonstrated the infant’s coordinated movement to the sound of the parent’s voice. The higher pitched lilt in the voice of the mother as she says “pretty baby” is matched by the crescendo of the infant’s foot reaching high in the air. When the mother picks up the tempo in her voice, the infant’s arms bicycle quickly in the air with a rhythm that mirrors the mother. Similarly, episodes of spontaneous sequenced hand movements of a 6 week old create proto-conversations that communicate changing states of vitality (Malloch and Trevarthen 2008). This research offers a glimpse at how the registration of sensory input is processed across perceptual modalities by the young infant and expressed in attunement with the parent. Sensory motor activity between the infant and parent come to take on affective meaning as the synchronization of sound and action are experienced as moments of connection and intimacy, or as momentary failures requiring repair, or as disappointments and discomfort requiring self-protective mechanisms of shut down and withdrawal. The rhythms of sensory motor -based interaction become dual coded with affective experience.

Synchronized Voice and Movement

In the following video clip you can see the early research by Condon and Sander (1974) demonstrating the cross-modal attunement between mother and baby in the newborn’s capacity to synchronize the bicycling of arms and legs to the prosody of the mother’s voice. First you will see this in live time, and then in slow motion to emphasize the synchrony of sound and movement. Hold in mind that this early nonverbal communication between parent and infant is so automatic and unconscious that it would only be noticed by its absence, and even then with a nonspecific inexplicable feeling in the parent.

 

Avoidance and Synchrony 

In this video you can see how hard the father is working to find the vocal and movement rhythm, intensity, volume, and pacing to match his 8 month old son and engage him in responsive attention. At first he can’t find the right tone or volume just to draw his son’s interest in his presence. Finally he uses his voice to match the baby’s movement with the ball, then he mirrors the baby’s movement with his own head and vocal rhythm that creates the affect attunement between them.  The baby becomes a partner in their shared experience. When the infant retreats and turns away to rest and regulate, the father changes the tune to create novelty, but maintains the pacing and intensity that drew the infant to him just a moment before.

 

Relationships are central to development

Recent work in psychoanalysis and infant development has sparked great interest in the earliest preverbal dynamic interpersonal systems. Clinicians and researchers investigate the origins of interpersonal connection both to learn about how relationships form the fulcrum of infant development, and to deepen understanding of the psychotherapeutic process. The work of the Boston Change Process Study Group (BCPSG) (2002, 2010), Stern (1985, 2010), Trevarthen (1998, 2009),Tronick (2007), and Beebe and Lachmann (1988, 2002) are examples of inquiries into how we know how to be with others long before we can walk or talk. This body of research is focused on the developmental path we take to comprehend and respond to the subjective experience of another person. Beebe and Lachmann (2014) refer to the moment –to-moment interactive processes that are rapid, subtle, co-created by both the mother and the infant, and are generally out of awareness.These processes have a profound affect on communication patterns, the affective climate of the relationship and the organization of different modes of relating.

The work of Meltzoff and Gopnik, (1993) centers on imitation and enters the world of the infant through inquiries about the shape of interaction and the goal. The work of Trevarthen, (1998) focuses on synchrony, and uses timing or the temporal aspects of interaction to explore the origins of intersubjectivity. Stern (1985) and Beebe (2005) investigate the time-intensity matching and the cross-modal perceptual matching Stern calls “affect-attunement”. Through these inquiries research approaches the question of what interactive details comprise maternal sensitivity, and what is the infant’s role. Infant-parent psychotherapies with infants and young children who show early signs of Autism, signs of not knowing how to be with others, offer the therapist unique opportunities to investigate the contribution of the infant to the dyadic system of co-regulation that emerges through the early relationship.

For example, we could speculate that infants who register multi-sensory input hyper- reactively or hypo-reactively would have a powerful effect on their caregiver’s innate responsiveness to the baby. What happens to a mother who waits in anticipation beyond her expectation for the baby to re-join her in mutual gaze, too long after the infant has gazed away to facilitate down regulation of arousal? She may feel confused and withdraw from the interaction, even by subtle shifts in her own facial expression or body tension, signaling the baby that she is no longer engaged. By observing the mutual disharmonies in early interaction patterns, therapists have an opportunity to apply this research to the therapeutic process by devising strategies for establishing connection between parent and infant through the dynamic experience created by affect, pacing, movement, sound, temporal sequences, rhythms, use of space, intensity and intention. By attending to all of these elements of dynamic experience simultaneously, the therapist can notice where the constrictions appear in the baby’s capacity for pleasurable sustained interaction, and where the caregiver’s sensitivity in how to elicit affective pleasure and attention in the baby is limited or shut down by overwhelming feelings or lack of understanding of the baby’s unique and idiosyncratic sensory- motor profile. By attending to the dynamic experience the baby is having with the primary caregiver, the therapist can support intimacy in the dyadic interaction for both, and provide developmental guidance for bringing the pair together affectively, rather than instructing the parent about interventions to “do to the baby.”

Here is an example.

An 11- month- old boy is poised on hands and knees about 5 feet from his mother. He looks up and catches her inviting expression, eyes wide, big smile, open arms, and soft voice calling his name. Accurately reading her affect cues and intention, his facial expression brightens as he begins to crawl toward her. She becomes excited by his approach, which can be observed in the marked increase in her voice volume as she begins to move her body toward him at a quicker tempo than he is moving in her direction. He freezes, drops close to the ground, while his facial expression transforms from excited pleasure to fear. The mother looks confused; her gaze shifts to the periphery of the room and her body stiffens. When the infant shuts down and fails to recover from the feeling of being overwhelmed and mismatched, the mother retreats. She sits up and turns her attention to something else in the room, leaving the infant to struggle alone with his internal experience of fright and freeze.

If we magnify this experience by the number of natural opportunities for similar misalignment throughout the day, occurring without repair strategies, one can imagine the vulnerability of this dyad for establishing homeostasis in a dysfunctional dynamic system. In the above example, the parent feels at least uneasy, if not rejected by the baby’s unexpected response, and she becomes self-protective and withdraws. Most babies would continue to respond positively to the increased intensity in the parent’s approach. So why would this baby freeze at such a robust invitation? He seems to have a very narrow window of well-regulated arousal, and the slightest unexpected surge in intensity of affect and action violates his anticipation of a rhythmic match of sound and movement. In an effort at self-regulation, he shuts out further input, facilitating a down regulation of arousal and lowering of his heart rate. What starts out for the newborn as an adaptive mechanism for self-regulation, such as shutting out extraneous sound in the service of falling asleep, can become a maladaptive response later in infancy, especially if the baby is overwhelmed by what one would consider an expectable range of sensory and motor input.

In identifying the trajectory that leads to later diagnoses of Autism, two factors are worth noting. One, the baby is behaving in self-protective ways that keep overwhelming stimuli from assaulting his fragile nervous system. The second is that the first is rarely the obvious explanation to the parent who feels emotionally rejected and confused, and withdraws from contact just in the moment the infant needs parental co-regulation most. The temptation for intervention strategies in such scenarios, on the part of the parent or the early interventionist, is to increase the stimulation, become bigger, louder and more intense, or to bring in other extraneous objects to distract the infant from distress. This frequently results in the infant becoming more shut down in the first case, or distracted by the object, but disengaged from the parent. The research on interactional synchrony supports practitioners and parents attention to matching the rhythms and intensity of affect, movement and sound. It indicates that the repair of the disrupted moment of engagement lies in the choreography between the parent and infant.   Early signs of Autism and implications for treatment are best understood through observation of the dynamic system that develops between the parent and infant, rather than looking only to the infant for behavioral markers. The baby’s behavior or reaction triggers an interactional system that inadvertently reinforces the shut down or avoidance patterns we see in young children with Autism.

The work of the therapist in the above scenario is to support the parent in understanding what is constricting the baby’s response, and reframing the feeling of rejection following her invitation to the baby. The parent is helped to see that the obstacle in the way is in the baby’s arousal system and registration of sensory input, and not his negative feelings toward his parent or the parent’s immediate feelings of inadequacy or hurt. If the therapist offers the insight and support the parent needs in order to regain the emotional vitality that will enable her to repair the missteps in interaction, the parent recovers her empathic connection to the baby, and the baby is supported by the parent’s attunement and capacity for co-regulation. The therapist helps the parent recover from the misaligned moment and match the infant’s rhythm. The mother is helped to change her use of space and intensity of affect by slowing down in body and voice, lowering her body, lowering her voice tone, and tolerating waiting for the baby to recover his movement toward her. Once the baby recovers and experiences the parental invitation resumed at the right pace, he can continue to move toward the parent and end up in her arms with an embrace that is reassuring to all and gives both parent and infant an experience of repair strategies that serve the growing intimacy of the relationship rather than reinforce a sense of withdrawal from relationship. The intervention addresses both the parent’s feeling state and the fundamental central nervous system force of arousal, from which actions initiate, perception and cognitions develop and emotions emerge.

Implicit relational knowing: how we know how to do things with others

Unlike more traditional forms of psychotherapy where attention to the semantic or symbolic representations in the form of language predominate, in infant-parent work procedural representations, or implicit relational knowing become salient (Tronick, 2007, Lyons-Ruth, 1998,1999, Beebe and Lachman, 1988,1994). Procedural representation informs us about how to do something, like ride a bicycle, whereas implicit relational knowing refers to how to do things with others that rely on affect and interaction. Infant research and psychoanalytic practice document the presence of this way of knowing long before language emerges. Acting on our understanding of how to be with others operates in full view, but often outside our focal attention throughout life. Infants with early signs of Autism make the most disorienting social partners, and by virtue of their inability to show typical recognition of the mental states of others (Baron-Cohen, Tager-Fusberg,& Cohen 1993) they bring vitality forms and implicit relational knowing into conscious awareness in their family relationships. By closely examining the early social interactions between these infants and their parents, one can see the effects of attempts and failures in the cycles of mutual regulation that build the sense of knowing and of being known in the relationship. The infant and parent find each other in their nonverbal exchanges where meanings are derived through rhythm, movement and sound. The next section will address the use of infant-parent therapeutic processes and the important role of the therapist in holding the parents and helping the parents make sense of seemingly senseless behavior, while sustaining the empathy for the infant that supports well attuned interactional synchrony in an otherwise disrupted system.

 

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About Barbara Kalmanson PhD

Barbara Kalmanson, PhD is a Licensed Psychologist and Special Educator in private practice in the San Francisco Bay Area. She is a National Fellow of Zero-to-Three, Senior Faculty for the Interdisciplinary Council for Developmental and Learning Disorders (ICDL) and Senior Faculty of the Profectum Foundation.