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Recognizing and Treating Early Signs of Autism: The Unseen Half of the Story (Part 4)



Recognizing and Treating Early Signs of Autism: The Unseen Half of the Story (Part 4)


In the previous articles in this series (Part Two: Recognizing and Treating Early Signs of Autism: Theory and Research, Part Three: Recognizing and Treating Early Signs of Autism: The Infant-Parent Therapeutic Process), Barbara Kalmanson demonstrates persuasively that focus on infant and parents’ nascent interactions may provide a better means of detecting newborns that are not naturally drawn to other humans. In the first three months of life, parents and newborns usually acquire states of composure, naturally notice and meet each other in a process of becoming social beings to each other.

But as we saw in the Part II videos, children who are born with atypical sensory-motor systems struggle with their caregivers to find these tranquil moments. Instead of rising mutual interest and pleasure, their encounters may be marked by distress, emotional flatness, desperation, and exhaustion. Whatever inherent interactive propensities the infant possesses are not sufficiently activated and go unnourished. As these first fruitless meetings multiply and dominate, parent and child are robbed of countless moments to sense and enjoy each other’s presence. They cannot find each other to establish the ever-enriching bond that supports the infant’s growth.

The Inside Story

This Part IV article turns the magnifying lens on the unseen half of the story. We are vitally interested in what we can observe by watching the overt behavior of infant – parent exchanges. However, we also contend overt behavior only tells us what is tangible, without learning how parent and infant separately construct images of what just happened between them. Every contact together form the foundation for their unified perceptions of how it feels to be in a relationship. With every give and take, newborn and parent instinctively work to “make sense” internally of every minute together. The ever-evolving, multi-sensory images infant and caregiver produce determine how each responds in the next micro-second. Over time these fragmented images coalesce to create the coherent whole that represents how it feels to be with the other, and eventually forms the expectations and generalizations one has about how she or he will be perceived and treated in all relationships.

For instance, father softly towels and wraps his four month old daughter, Emily, after a bath. She feels his ministrations as soothing and warming her body. Instantaneously, she encodes those sensations as pleasurable along with smiling father’s motions, scent, deep voice, and scratchy face. In turn, Emily coos and enfolds herself into father’s neck and shoulder. As father feels his baby girl snuggle in, he soaks in her embrace. Internally, he is electrified by their organic unity, “maps” Emily’s sensory preferences for touch, temperature, and body position, and endeavors to continue their mutual enchantment while dressing his daughter for bed. Father’s sensitive handling immediately elicited Emily’s multi-sensory thrill, registration of father’s satisfying touch and body followed by her seeking and nestling into him deepening their physical harmony. Likewise, Emily’s initial caress thrilled her father producing in his mind a rapturous schema of her physical contentment sparking his gently laying her down as they beam at each other. Outer behavior and resulting dynamically colored perceptions then continue interdependently to inform and define each other. Subsequently, each back and forth interaction endlessly reshapes not only the parent-infant’s dynamic behavior but their respective sense of their individual selves, their partner, and their expanding attachment. The visible actions of mutual regulation and affect attunement are paralleled by the unseen emergence of implicit relational knowing, internal models, and intersubjectivity (all defined in Part II).

The Fragile Parent- High Risk Infant Bond

Infant development research supports the critical role internal operations play in shaping a secure emotional bond in the parent-infant relationship. Any child’s growth as well as the quality of the dyadic relationship are likely to be less than optimal unless both inner recognition and outer charged connections are working, feeding each other, and maturing together (see reviews in Aitken & Trevarthen, 1997; Trevarthen & Aitken, 2001; Feldman et al, 2007). When the mismatches and dysregulation illustrated in Parts II & III dominate their original gatherings, parent and highrisk (HR) infant are challenged to cultivate consistent, positive exchanges, and unified schemes.

The unseen consequence of these troubled beginnings is that both parent and infant (at their own levels) are apt to create distorted images and meanings from their fledgling contacts. In turn, these muddled inner perceptions become adverse expectations that progressively determine subsequent responses to each other. As in harmonious encounters, each fractured scenario inherently creates a revamped internal scheme of that moment. So when these disruptive representations multiply and assemble, parent and infant anticipate their contacts will be injurious sparking avoidance and secondary damage.

Without clinicians recognizing and intervening as early as possible, these deteriorating patterns will rapidly evolve into relational disturbances driven by entrenched apprehensions for both parent and infant. By outlining this unseen action, the additional aim here is to amplify the argument that the vulnerable relationship between the HR infant and parent is apt to be the first and most powerful source to uncover, prevent, and ameliorate early signs of ASD. The partnership unsteadily labors to produce its own living energy composed of two engines: (1) parent and infant affectively signaling and responding to each other, (2) within parent and baby, these outer actions/sensations are fueled by and imbued with Vitality Affects ( Stern,1985; 2010) which create inner meanings and formations (of self, other, & dyadic interaction). Altogether, they determine their very next response.

Shortly, we will revisit the compelling video cases from Part II taking  “psychological x-rays” of parent and child to better capture what manifest behavior implies about their internal worlds. Before doing so, we will briefly outline recent research on the early detection of ASD to digest how its findings and shortcomings lead directly to the pressing need for a more complete investigation of the observable interactions and internal worlds of the parent-high risk infant bond.  In essence, we will see  that much of early ASD detection research has largely neglected two crucial determinants: (1) the potent contribution of imperceptible, psychological processes to relationship-making, (2) how the moment-to-moment dynamic, reciprocal influence parent and  HR infant have on each other and ultimately, the nature of their relationship. More precisely pinpointing how behavior and inner charged perceptions chemically mix together may illuminate the first anomalous expressions of partners struggling to greet each other. Such an invaluable contribution could eventually revolutionize clinical ASD interventions in two major ways.

  1. Earlier Diagnosis– Discern specific, disrupted dyadic interplay within the first two to six months that are harbingers of an infant who is apt to later be diagnosed with ASD.
  2. Earlier Intervention– Equipped with these characteristic interactive markers, we can equip parents with tools to catalyze synchronous, affectively-attuned encounters with their vulnerable infants. Understanding and respect for their baby’s sensory-motor traits will guide them towards shaping a more consistently, harmonious relationship while diminishing mismatched responses and misconstrued internal notions of the self, the other, and their sacred bond.




The most extensive focus in early detection of ASD literature has been to find markers through exclusive study of the HR/ASD infant or child with ASD in three chief areas: hallmark ASD symptoms, compromised core developmental capacities, and pervasive sensory-motor disabilities. Through scores of experiments and reviews, ASD experts have made two clear broad conclusions from their exhaustive efforts. First, all three of the ASD common characteristics arise at different chronological ages (Landa et al, 2013) or not at all until 12-36 months (Pineda et al, 2015). Second, this research has made it abundantly clear that heterogeneity is the signature component of the ASD population (Aldred et al, 2004; Lord & Somer, 2010; Mitchell et al, 2011; Jones et al, 2014). In stark contrast from the search for early behavioral-markers of ASD, other scientists have vigorously pursued pinpointing irregular sensory operations in HR infants that distinguish them from typical autonomic nervous system (ANS) growth. These technical studies have found various-aspects of eye gaze to be the most consistent differences seen in infants eventually diagnosed with ASD after three years of age. These physiological evaluations will be discussed later in conjunction with efforts to link them to overt infant behavior and the nature of dyadic-exchanges.


Critical Characteristics of Parents’ Interaction Style

Other developmentally oriented early ASD detection researchers inspected parents’ interaction styles and conducted parent-mediated intervention studies.   Authors have sought to tease out aspects of parents’ actions with and inner perceptions of  their HR/ASD children that jointly galvanize more consistent engagement. Through systematic surveys, they have established that parents who respond sensitively to their HR/ASD children (12-60 months) generally produce various favorable results including reduced ASD symptoms and improved social behavior (Oppenheim et al, 2014). Clinical treatment outcomes also consistently align with early developmental models in finding that initially strengthening joint engagement (JE) lays the groundwork for the oft targeted ability of the dyad to achieve joint attention (JA), (Aldred et al, 2004; Kasari et al, 2010; Green et al, 2010).

Parents’ Internal Conceptions & Overt Dyadic Functioning 

Two novel sets of studies have concentrated more on the corresponding influence of or between caregivers’ internal views of and hands-on responses to their HR toddlers. In a series of parent-mediated treatment programs, investigators repeatedly learned that parents who possessed, developed, and blended their lively interactive style with psychological understanding of their child resulted in their children attaining the strongest levels of joint engagement (Siller and Sigman 2002, 2013; Gulsrud et al, 2010; Kasari et al, 2015).  This coupling of parents’ inner images and manifest behavior further exhibits the predictive value of early developmental and attachment perspectives for HR populations. This conclusion was echoed by two completed infant pilot studies (Green et al, 2013; Rogers et al, 2014). In the process of identifying and successfully treating HR infants (7-15 months) and mothers, each group informally commented that both tangibly shifting communication and parents’ crystallizing sense of their HR infant had a broad impact in their abbreviated treatments.


Several teams of scientists have produced through systematic canvassing quite enlightening, initial data through exclusive focus on the HR infants’ deteriorating desire for synchronous contact with parents. Extraordinary among these novel explorations is Wan et al’s(2013) examination that found the infant’s weak attentiveness to parent and lack of positive affect were accompanied by poor dyadic mutuality at 12 months (though not at 6 months). Collectively, all three of these factors, not dyadic interaction alone, predicted a later diagnosis of ASD at 3 years.

Jones and Klin’s,(2013), survey went on to find a cohort of HR newborns later diagnosed with ASD began displaying declining eye-watching between 2-6 months. Notably, they demonstrated that, prior to two months, this basic social mechanism was developing typically in this group. Hence, these experts recommend rigorous, ongoing screening of all HR infants.Their proposal is strongly supported by Elsabbagh et al’s (2015) review that found consistent evidence of HR infant’s fading social behavior sometimes accompanied by atypical eye gaze both of which may first appear from a few months through the child’s first birthday.

Green et al’s (2015) completed, multi-year project is the first treatment study that tests several hypotheses about the parent- HR infant bond and how it may be impacted by vulnerable visual operations. These investigators offer potent current data from which to further grasp the real, unfolding action between the HR infant and parent. Adopting previous research (cited above) on parents’ conception of their HR infant,  Green and colleagues’ made raising parents’ understanding of their infant’s communications their primary treatment goal. Through methodically recognizing their child’s everyday desires, parents increasingly produced emotionally attuned responses thereby kindling more sustained dyadic contact. By 14 months, the treated HR infants’ attentiveness to parent improved more than any other measured effect in the study. Further, several interactive outcomes were positively effected by the intervention. Namely, parents developed a better non-directive interaction style while infants’ atypical, autistic-like behaviors significantly decreased along with simultaneous advances in their adaptive behavior. In addition, the babies demonstrated stronger (physiologically measured) visual attention and flexibility. Essentially, their therapeutic approach reversed the highly suspected patterns of dwindling visual attention and social interest in HR infants (Elsabbagh et al, 2015) both often considered the earliest, reliable markers for an eventual ASD diagnosis (Klin et al, 2015; Elsabbagh et al, 2015). The authors’ original treatment approach and outcomes offer exciting, detailed data and implications that hopefully propel clinical replication projects. Utilizing Green and colleagues’ unique findings in follow-up research will bring us one step closer to grasping how the at-risk dyad initially signals they are laboring to “find each other”.


The innovative parent-mediated research offers compelling evidence that the internal lives of mothers of HR/ASD children must be considered in any dyadic intervention program (fathers not included in these studies). These studies show that the maternal sensitivity described in Part III by grief and sadness can be transformed by revising parents’ conception of their babies’ atypical sensory-motor responses. Moreover, these original experiments (cited above) demonstrate that the powerful blending of caregivers’ insight and well-attuned play best equips parents to introduce their compromised toddlers to the wonders of human relationships. Further, we are more fully enlightened how HR infants’ bring their own intrinsic makeup into the mix as they may effectively disrupt building shared attention into synchronous dialogue. Knowing mutual gaze is a vital means for every parent and child to truly meet, the HR infant’s ebbing eye contact and social responsiveness may provoke despair in the parent that his HR infant is unreachable.Without realizing his baby is unable to typically interact, the parent may move away, slump into tears, or demand recognition. Altogether, the more current research focus on the parent-HR infant relationship provides powerful evidence that the original indicators of a compromised infant are apt to first emerge in irregular encounters with his caregiver. Given these disturbed interaction processes may first manifest themselves throughout the first year of life and beyond,tracking all at-risk dyads appears highly warranted.

What if the Emily described previously in the post-bathing scene with her father was an infant with pervasive sensory-motor anomalies? Their cherished moments would no doubt be much harder to achieve. Emily loves the warm water, the splashing, and happily does simple water play with her father until it is time to wash her hair. Then she reacts violently to water poured over her head, rubbing her scalp, and washing off the shampoo into her face. Father washes and speaks to Emily as gently as possible but is gradually becoming frantic about Emily’s distress. Mother brings heated towels and lowers the bathroom lights. Father hugs Emily which quiets her a little but not significantly until father realizes she needs to be able to change her body positions while in his arms. This takes over 30 minutes. It is not only the fragile infant who has to recover but father as well. Once Emily is supine, she slowly looks at father while he dresses her. They are re-regulating together. Both are breathing slowly, sensing a welcome silence; i.e. mutual regulation. He hums a lullaby as Emily sighs and even coos. This is their magic moment. In this scenario, the prolonged distress, the arduous recovery, and brief contentment are all shared by father and daughter. These qualities can only be the property of the relationship. It is the irregularities, lack of sustainability, disruptions, and incompatible affect states in these scenes that promise to reveal the first ominous signs of emerging ASD.



Below we fantasize and illustrate the play-by-play of father’s and infant’s inner “sense-making” of what they experience while we witness their shifting together. We recognize this father is working at wooing his infant son into sustained shared attention and reciprocal engagement. We will give each of them an inner “voice” to detail their individual somato-sensory feelings, precipitating images, and consequent replies. All this internal action will be inscribed in italics.  


(Father) F –  “ See if Baby likes rolling and pushing this drum.

 Let’s see … ”

 –      Rolls drum to Baby, quickly takes it back before he can hit it.

Hmm, I’m not really getting his interest. Try again”

 –   Rolls it to Baby again observing how he has tapped Baby’s attention and interest. But Baby is focused on the object, the  drum, and not on what rolling the drum together means to them.

(Baby) B –   “ Hmmm, what is that? Doing? Coming to me from                  

DaDa .… spins, makes little noise. Dada                  

push so…hmmm….feels hard, my arm                  

moves it (like DaDa), push (like DaDa) …                   

Yes, moves, circles, that sound (with touch,                  

vision, joints/muscles) “

 –    Simultaneously, B swings hand & arm, drum rolls back to F

 –    “Ah, it goes back to DaDa         I know it now.”

F –  “ Good, B got it quickly imitating me…… but did

          not excite him. He’s focused on the drum, not us

          together.” “ What can I add?”  See if I can make

          it more fun ….. for both of us.”

 –      As B rolls drum back, Father intones a moderate “Whew !!”

B –  “ Oh, Dada’s nice sound with it going back…. Ripple

            in my chest, my skin….. want more, make it all bigger!”

 –      B  grabs the drum, banging it on the floor. Not signaling (no eye contact) clearly if he wants father to join him or alone explore alternative actions with the drum. He looks for more volume, intensity and force in the interaction.

F –  Wow !! He’s got his own idea….. More energy !

          B grabbed, banged so strongly! Get more charged

          up together. Show him I know how he feels,  Join

          Banging….B wants fire!”

 –       Father looks in wonderment, eyes brighten, big smile, and synchronized in time with Baby’s drum banging he takes a deep inhale which alerts Baby to look up at him, and then he says “oh” which catches Baby’s gaze,  and warmly says  .

         “Bang, Bang, Bang !!! “

 B –  “ Makes happy noises like me. Flutter in my  tummy …Bigger !!”

 –      Now B looks right at father who is pacing his voice to the banging. B starts smiling, looking to father, anticipating father’s spirited response.

 F-   “ B really excited, banging more, sees my enthusiasm,

           sharing his fun. Get really exuberant  all over !”

 –      As F sees B look at him, he dramatically brightens his face, shakes his head and repeats more excitedly (all in  rhythm with B using cross-modal matching tempo with F’s new banging)


B-  “ Yes, yes, yes !! Even more wonderful !! I shake,  

head tingles, skin buzzes, laughing from my warm tummy……            

 DaDa’s face, noise, moving,  feeling it together…. Now DaDa does it!” 

  –     Baby starts bouncing in rhythmic response to the prosody of father’s vocalizations. Beaming at his father, he spontaneously raises his arms up and gives the drum to Father to make the noise and increase their joint intoxication.

When F injected some moderate cross-modal vocal energy into the drum rolling, B lit up inside and signaled so clearly by banging the drum. B had the experience of feeling F knows what it feels like to be me.  There was no mistaking what B craved so F magnified their tangible electricity. However, this happy scene might not have happened if the play unfolded differently. For instance, what if F read that B was not interested in the drum when B initially showed little enthusiasm? Or F’s “Whew!” startled B and he began crying?

Now let us view a different video clip showing a different activity (Part II-Video #3) to see that behavior and sensitive reading team up to allow for needed adaptive corrections. Barbara Kalmanson highlighted how Father had to initially make himself attractive to Baby by changing his tone, rhythm, and movement to ignite mutual pleasure. I want to emphasize the latter part of their pleasurable interaction. Tune in to what follows immediately after Baby imitates Father’s big open-mouth movement (at 40 seconds).  

F“ Ah, B’s smile! my voice & head going together to his

        shaking his arm and bouncing. My face is glowing !”

   –   Father keeps varying head and voice to offer the physical attributes that created the affective connection, and matches the rhythm that attracted his son to him. Father works to keep the Vitality Affects strong between them.

 B- “Feel arms, body’ energy for ‘beat,beat,beat’ with

         DaDa’s sound and bouncing head”

       “ Oh, arm aches, it’s so fast, my breath, looking at

          his jumping face. Find quiet”

   –   B slows, looks away from F by looking to his right. Strokes his pillow.

   F- B stopped, looked over there. Distracted? Too much?

          Bored? No, he does that sometimes, takes a time out”

   –   Confident B is briefly pausing, he lowers his voice, rhythm, and intensity then makes the more tranquil sound of wind blowing showing recognition that there was a break in the connection and an understanding that B needs to modulate his arousal.

    B- “ Hmmm….. DaDa’s sound like my chest up and down.

           Together it is soft”

   –    Looks back at F, B smiles then greets with more modulated face, sound, movement.

     F-I knew it…. just a breather. Ok, again with my smile,

           eyes, bobbing and clicking. Yes, he wants more and so do I !”

   –     Father quickly turns up the volume on all his gestures

     B- “ Oh, not quieter now. I want it easier, no more buzzing.

            I watch, wait for slower”

   –    As F intensifies, B’s face becomes sober. He is observing F’s raised activity



At this moment in their lively exchange, Father and Baby’s work is to refine their gestural language to sustain a common, co-regulated, and harmonious state. Baby signals with his facial expression and Father is to notice and internally realize Baby wants their enthusiastic play to continue at a mutually modified level. Father responds by slowing down, and comments more melodically, “hello there”. In his first months of life, this baby’s fragile social capacities were observed and addressed through his fledgling meetings with his parents. As a result, father and son are becoming equipped to dynamically enrich their bond. However, this intervention model does not yet appear to receive appropriate notice in ASD early detection clinical research or practice.


By 2 months of age, infants are typically using gaze to initiate, sustain and terminate social contact with their caregivers. Without the use of technological screening devices, the caregivers of young infants can often recognize a choreographic mismatch or challenge to engage their baby in social contact for its own sake. As clinicians, we should take seriously any parents’ concerns regarding their infant’s sociability. Clinicians can provide crucial early intervention by supporting the caregivers increased understanding of the individual profile of their baby, helping parents gain empathy for their infant’s challenges, and helping parents learn how to draw their baby into social contact.


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