Library of the History of Autism Research



Infantile autism: a family approach

International Journal of Group Psychotherapy 1964 Jul;14:360-5

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The syndrome of autism in young children is being reported with increasing frequency, but whether this is due to a growing incidence or to increased awareness of the phenomena is as yet not clear. Sancte DeSanctis (1925) originally described childhood psychosis as dementia precocissima. Bradley (1947), Spitz (1946), Well (1953), Kanner (1959), Schilder (1935), Ribble (1941), Bender (1947), and Mahler (1952) furthered the diagnosis and the conception of childhood psychosis. Kanner, in the forties, described the syndrome he called "infantile autism." This condition is characterized by profound withdrawal, obsessive demand for sameness in the environment, lack of communication in the use of language, and preference for relationship with inanimate objects. Kanner stated, "The entire symptomatology and behavior pattern of the infantile autistic syndrome is formed around the fact that the autistic infant or child is unable to utilize the auxiliary, executive ego functions of the symbiotic partner, the mother, to orient himself in the outside or the inner world." He also went on to say, "It would seem that autism is the basic defense attitude of these children by whom the beacon of emotional orientations, the living primary love object, the mother, cannot be utilized, that is to say is functionally non-existent as such. The child, devoid of emotional ties, is unable to cope with the complexities of external stimuli and inner excitations that simultaneously threaten his very existence as an individual entity." In the behavior of the autistic child we see sameness, stereotyped actions, a dereistic life space walled off by magical ritualistic gestures, and a preoccupation with a few inanimate objects that are used not as the objects themselves would be ordinarily but as extensions of the child. The autistic child appears to want no change, to want to live alone. Yet, as has been observed, many are physically attractive and have intelligent looking faces. There frequently is a lack of speech, or manifest echolalia, with what little communication going on being primarily through the modes of gesture and vocalizing. A number of these children have first been brought to our attention because they were thought to be mentally retarded or even to be deaf.

The autistic child appears to be unable to integrate or to respond to stimuli, both from an internal source, the body, as well as from external sources, such as human contact. We have noted in the children at our residential treatment center how in their preliminary period with us, they appear to be unaware of their body; they give the impression of being insensitive to pain, display little autoerotic behavior, inflict injury on themselves, such as hitting their heads against objects and biting their own bodies, with little outward display of distress. In working with these children in therapy, one of the guideposts for change and for growth is a display on the child's part of an increased body awareness and autoerotic behavior. For example, one child who developed polio during his early stay at the clinic residence did not communicate this to anyone and it was only made known by observing the child's dragging one leg ( Memorial Guidance Clinic, 1959). Later, he was able to point to his body and to indicate pain. Another child, who at first seemed to be quite unaware of both himself and others, concurrent with his growing display of affective expression toward the therapist also manifested pleasure through genital stimulation, was quite ticklish, and when injured would display the area of pain quite readily.

Growth seems, therefore, to parallel increased ability to cathect the body. Following an increased body cathexis, the child appears to be able to invest in people in his environment; usually this is tentative and has a fluctuating quality but it represents the development of object relationship. At this point, we feel the child has begun reality orientation because of his growing capacity to invest in someone outside of himself. To illustrate, an eight-year-old boy who had displayed an almost total unrelatedness to either other humans or to his own body and would not report body discomfort was observed one day in a situation in which another child sunk his teeth into the fleshy part of his arm. No response was evident until apparently the pain was considerable, but then, in contradistinction to his previous behavior, he turned on the tormentor, knocked him down, and sought out the teacher to comfort him. Since then, he has gradually become freer in his communication about personal discomfort, wanting sore spots to be kissed and wanting to be cuddled, and he has become competitive with other children for the attention of the teacher.

As regards separating the self from others and the response to external influences, namely, the relationship with the "important humans" in their life, some light has been thrown on this by our experience with the parents of these children in group therapy. Based on such experience, we feel that we are dealing in many instances with a reaction to experiential phenomena. The important relationship apparently for the development of this syndrome, judging by the many parents involved in our therapy groups, seems to be the mother-child relationship (Memorial Guidance Clinic, 1961).

The mothers in the group have stated from time to time or have indicated to the group that they had at a very early stage in the life of their child a need to appropriate this child to fill some, either vaguely or acutely perceived, lack in their own personality, a need to use the child as a vehicle for living through of their feelings of great frustration and anxiety in their own lives, to minimize their sense of emptiness or incompleteness.

Some of the mothers reported feelings for their child which could be described as desires for "annihilation" of the child. Sometimes this annihilation was a displacement of their own feelings of being overwhelmed and destroyed. The child very often reacted with fear, sometimes with rage, and then gradually withdrew and became nonresponsive. While this withdrawal would frighten these mothers, it was very difficult for them, particularly early in therapy, to even consider that there might be some relationship between this behavior and their own personal feelings of incompleteness and destruction. As therapy progressed, three of the mothers in one group spoke of their feelings coming more to their awareness as the child began to show increasing withdrawal behavior, negativism, and ritualistic, stereotyped reactions. The feelings they described reached such intensity at times that several of the mothers had literally to flee physically. Some locked themselves in the bathroom, several ran out of their homes, and all of them had intense panic states accompanied by feelings of unreality and fear that they would destroy the child.

Rather than being a result of earlier described feelings of incompleteness and sense of annihilation, these feelings appeared to the therapist to be more a continuation and an extension of them. Although these mothers were concerned with the unacceptability and the "unnaturalness" of their feelings and were consequently quite guilt-ridden, the sense of guilt appeared to be an extremely primitive type that was often associated with retributive feelings toward the source of their own anxiety and for the threats of annihilation that had occurred at an earlier time in their own life as children.

As for the fathers of these children, their role seems to concern itself almost universally with an attitude of competition with the child for the mother-like qualities possessed by the mother. Most of the fathers in our groups could be described as being relatively passive, benign, and tending toward a depressed orientation. Although there was no strong evidence of confusion in sexual identity, there seemed to be fairly constant role confusion on the part of both parents. A frequent finding for both parents was that the time of conception and the early months of life of the child occurred during a time when the stress on the parents was greater than usual. Personality profiles based on Rorschach findings were characterized by early narcissistic injury and arrest in these parents, suggesting that under stressful situations they revert to competition, flight, and appropriation of the child to meet their needs. The angrier and more demanding of these dependent fathers would frequently be punitive toward the child. They usually would then work the punitiveness out and end up identifying with the child's dilemma, often finding things to accept in the child. While the fathers appeared to be very dependent on their wives, many were able to create a job situation in which some aspect of their identity was intact, such as being an engineer, bus driver, forester, social worker, etc., and this represented at least one avenue for gratification and maintenance of self-esteem. Most of these parents were bright intellectually.

THE COURSE OF THERAPY

The course of therapy is frequently punctuated by considerable effort on the part of the parents to develop elaborate explanations of their child's disturbance, efforts greater than those ordinarily seen in parents of non-autistic children. For example, there have been inquiries about the effect of electricity on their children, the influence of atomic fallout, and the role of drinking wine on cellular function; many exhibit a preoccupation with literature dealing with mystical influences on behavior. Even with the most protracted therapy, whenever the area of relatedness of the child's problems to the parents comes into the foreground, there is a general rise in anxiety, a resort to primitive mechanisms of somatization, and a remarshalling of the many previous, elaborate rationalizations that have been worked out by these families. All of the parents appear to be searching for an authoritative stand that will preclude any consideration that they might be in the final analysis the "cause" of the problem in their child. This is particularly interesting in view of the fact that most of the families ordinarily have an excellent command of semantics and logic, making their lack of a grasp of the cause and effect relationship as it applies to human experience quite striking.

There are times when these parents do occasionally toy with the idea that they may be importantly involved in the problem of their child, but they choose to see this in terms of their being importantly involved in his further growth and do not accept entirely that the same degree of importance might have attached to them in his earlier formative years. It is a logic of convenience and self-protection. It precludes, except in extremely small doses, the possibility of there being a meaningful relationship between what the child has experienced in them and the problems that he presents. To a degree true of no other group we have worked with, the parents keep calling continuously into the foreground the child as the special consideration and studiously, oftentimes with great tenacity, avoid viewing consideration of their own feelings and problems as a legitimate effort. Because of this, we have found it extremely useful to have parents of children with dissimilar disorders in the group with these parents. They not only cause them to stand out in bold relief but they demonstrate to them the greater degree of understanding other parents can achieve of their role in the kinds of maladjustments and disorders of personality demonstrated by their children. More often than not, preceding real movement in the autistic child, there is a dry run on the part of the parents during which they attempt to verbalize what improvement would be like, as if each inch of the way must be pre-prescribed. Great anxiety and timidity and at times flight into illness on the part of the parents occur when the child proceeds at a rate that is not readily graspable by the parents.

An attitude that appears quite frequently in therapy with these parents is the idea that their children are somehow a subhuman species that cannot be understood. On many occasions, they reveal that they have all but deprived the child of his identity, to the extent that they talk about him as if they were talking about some inanimate object. The child has no identity in their own minds; instead, they are speaking through the child of their own injured personal identity. This is most true of the mothers of these children. The fathers, in contrast, are more apt to describe their children as deviant individuals, using judgmental terms, rather than depriving them of basic identity as a fellow human being. Frequently, the parents express the hope that their child's problems are a transient phase of maladjustment in development, and they suggest that if they leave the child alone, perhaps somehow he will change. Beneath this expression, especially on the part of the mother, are desperate fears and guilt, and this attempt at flight into health is an attempt to deny the existence and the seriousness of the problem.

Witnessing these parents in contact with their children, their ambivalence is striking; the child is dealt with a degree of disdain, distance, and incomprehensibility, yet at the same time there is an all-consuming preoccupation with the child, particularly on the part of the mother. This ambivalence suggests some kind of terrible personal indictment that can only be experienced on an intensely private, irrational, and guilt-laden level. These children, then, in the final analysis, seem to represent an ex tension of and reaction to early narcissistic injury in the mothers, coupled with the dependent personalities of the fathers who are selected in part to be the defense against the mothers' own retaliatory impulses.

 

REFERENCES

Bender, L. (1947), Childhood Schizophrenia. Am. J. Orthopsychiat., 27:68.
Bradley, C. (1947), Early Evidence of Psychoses in Children. With Special Reference to Schizophrenia. J. Pediat., 30:529.
DeSanctis, S. (1925), Neuropsichiatria Infantile, Patalogia a Diagnostica. Turin: Lattes.
Gordon, F. F. (1961), The World of the Autistic Child. Virginia Medical Monthly, 88.
Kanner, L. (1959), The Syndrome of Infantile Autism. In S. Arieti (ed.), American Handbook of Psychiatry. New York: Basic Books.
Mahler, M. (1952), On Child Psychosis and Schizophrenia: Autistic and Symbiotic ,.Infantile Psychoses. In R. S. Eissler, et al. (eds.), The Psychoanalytic Study of the Child, 7:286-305. New York: International Universities Press.
Memorial Guidance Clinic (1959), Ritualistic Behavior in Autistic Children (Film). Richmond, Va.
-------- 1961, Children in Search of a Self ( Film). Richmond, Va.
Ribble, M. (1941), Disorganizing Factors in Infant Personality. Am. J. Psychiat., 98:459. Wilder, P. (1935), The Image and Appearance of the Human Body. New York: International Universities Press, 1950.
Spitz, R. A. (1946), Anaclitic Depression. In R. S. Eissler, et al. (eds.), The Psycho-analytic Study of the Child, 2:313-342. New York: International Universities Press.
------- (1959), A Genetic Field Theory of Ego Formation. New York: International Universities Press.
Well, A. P. (1953), Certain Severe Disturbances of Ego Development in Childhood. In R. S. Eissler, et al. (eds.), The Psychoanalytic Study of the Child, 8:271-287. New York: International Universities Press.

Senior author's address: Memorial Guidance Clinic, 3001 Fifth Avenue at Brookland Park Blvd. Richmond 22, Va.


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