Michael Isn’t Talking: Autism or something else?

Autism or Something Else? is the title of an article in ABC News today by Dr. John Constantino, associate professor of psychiatry and pediatrics at the Washington University School of Medicine in St.Louis. Dr. Constantino describes a toddler, “Michael,” whose “parents have started to worry”: Michael isn’t talking. Checklists of skills Michael at 18 months should be able to perform (”point to things that he is interested in”; “follow simple commands”) and should not (”sit alone for a long time without seeking someone else’s attention”) are provided, though autism is not specifically mentioned till about two-thirds into the article.

The area of development that Dr. Constantino particularly highlights is “social competence”; he emphasizes the extent to which autistic children do not have a motivation “to interact with family or friends”:

By 18 months, children should be learning to strike a balance between the two fundamental forces of all human social relationships: the capacity for intimacy (attachment) and the longing for autonomy (separation).

All great relationships (at any age) represent a harmonious balance between these two seemingly opposing needs, and typically, young children are driven to master the integration of these primary motivations from a very early age.

Dr. Constantino uses the example of an autistic child preferring the sound of a doorbell over that of the human voice to suggest how “such early preferences might result in abnormalities in the manner in which socially relevant information is normally perceived.” He does not mention another reason why an autistic child might exhibit such a preference for a mechnical, non-human sound: Many autistic persons have difficulties processing sensory data. Sounds made by mechanical devices, such as a microwave oven or a garage door (whose noise was my son Charlie’s particular favorite to imitate when he was younger), are always the same and are attached to a certain setting (food being heated up, the car going into or out of the garage). Conversely, the human voice varies not only from person to person, but from moment to moment: Its volume can be loud or soft, its tone shrill or low; words can be spoken fast or slow.

I am glad to see Dr. Constantino’s call for urging parents of young children who suspect that “autism or something else” might be possible. While he notes that “interventions” for young children with developmental disorders are “increasingly sophisticated,” he notes that “parents can handle a lot of these treatments themselves at home, especially when the treatment is put into the context of play time.” The suggestions that he offers are all play-based activities (”playing with action figures, puppets or stuffed animals gives children added experience in forming mental images of thoughts and feelings that are critical to the development of language”) and recall play therapy.

Dr. Constantino’s emphasis on autistic children’s difficulty forming relationships and on attaching with caregivers recalls the work of Dr. Stanley Greenspan of the George Washington University School of Medicine and author of several books on child development including, most recently, Engaging Autism: The Floortime Approach to Helping Children Relate, Communicate and Think with the DIR/Floortime Approach. In this book, as I noted in previous posts, Greenspan suggests that children are “at risk” for developing an autism spectrum disorder as a result of not being in an environment that can best foster their relational and emotional development. Dr. Constantino also emphasizes children’s relationships, and in particular “their first attachment relationship” with a parent or caregiver as “the most powerful in a child’s life” (see Children’s earliest relationships set the stage for life). Dr. Constantino further states that

“The absence of a secure attachment relationship … essentially doubles the relative risk the child will have a significant mental health problem over the course of childhood.”

In other words, it is suggested that children are “at risk” for developing autism because they do not “bond” with their primary caregiver (their parents)—–an explanation for the development of autism that has more than a few echoes of the refrigerator mother theory of autism, which was promulgated by Bruno Bettelheim and which, among the parents of autistic children who I know, is thought to be widely discredited.

But after reading Dr. Constantino on Autism or Something Else? in ABC News this morning, I am not so sure.