Abstract
This prospective case study illustrates the ideas on the developmental origins of some cases of autism that were described in Part 1 of this article. We explored and found support for several systemic hypotheses regarding the experience of ‘Graeme’ and his mother. Graeme’s story is told prospectively from the age of 3 until 15. Three independent sources of information are reported: hypotheses from the literature and case review in Part 1 of this article, the school’s experience, and observations from the assessments of attachment when Graeme was turning 6. These three streams of information are integrated here. The review of the literature and clinical cases gives us a wide-angle lens, empirically supporting our focus on danger in relationships. The school’s experience describes working with a child with undiagnosed autism. The assessments of attachment both provide information about family members’ psychological strategies for protection from danger and also include the mother’s childhood history of family threat. Their synthesis permits us to construct a developmental history, from Graeme’s mother’s childhood history of being triangulated into her parents’ hidden marital discord to it’s repetition for Graeme in her own marriage. New observations included mum’s postural/gestural communication to Graeme and her possible ambivalence about males. Strikingly, Graeme was a case study (Attachment & Family Therapy, ch. 6) before he was diagnosed with autism. That presentation focused on Graeme’s feeling of rejection by his father. In the same book, an interpersonal formulation of autism was offered (ch. 3), but it was not connected to Graeme, showing that when one lacks crucial information, the clinical formulation is distorted. The crucial information in this case was the mother’s psychological history. Our case suggests that filling the blind spot in the research on autism with information about family functioning over at least two generations might change the understanding of autism in ways that could help families and their children.
Keywords
Introduction
I write to inform you, in the nicest possible way, that there is a lack of training in schools with regards to children having individual needs. I have endured people looking down their nose at me because my child behaves in a way that is different to other children. I have faced negative attitudes towards my parenting skills and my ability to cope as a mother. My child has been punished no end and there were plenty of opportunities for things to be done differently. My child is not naughty, he does not have a bad attitude, he does not purposely wind people up, he is not rude and he most certainly does not deserve to have suffered until 14 years of age for this to be recognised. My child has slipped through the net numerous times and suffered immensely due to the inability of professionals to recognise the signs that were evident from as young as infant school. My child was yesterday diagnosed ASC, Autism Spectrum Condition.
1
This excerpt from an exceptionally articulate letter reflects the experience of many parents of children diagnosed with autism. It is unusual because ‘Graeme’ 2 lived in a small, cohesive community where children and their families were known over many years and where a research project, when Graeme was turning 6, left an objective record of his family’s functioning at that time. These conditions allowed us to gather information prospectively from Graeme’s entry into Infant School at age 3 until he was 15, a year after he was diagnosed with autism. When he was 8, his experience was used as a case example of the detrimental effects of paternal rejection (Crittenden, Dallos, Landini, & Kozlowska, 2014). After his diagnosis of autism, we decided to offer this follow-up case study that brings together the literature on autism, the school’s perspective, attachment classifications and a research-based re-examination of the Dynamic-Maturational Model of Attachment and Adaptation (DMM) assessments of attachment.
In this article, we ask whether there was early evidence of fundamental processes that could have led to an alternative route forward, one that might have eased the problems without a decade of frustration that ended only with a diagnosis and not a solution. Graeme and his mother have generously consented to share their experience for the purpose of helping schools to find more effective and speedy ways to help children with autism. Graeme’s mother’s commitment to her son and her bravery in the face of unsettling information made this report possible. We think such commitment characterizes parents of children with a diagnosis of autism.
This prospective case study is divided into three parts: the school’s experience with Graeme, the research-based evidence from three assessments of attachment and a Family Functional Formulation (FFF) of Graeme’s situation. Each section includes the information that was deemed relevant in its context, even if the synthesis would suggest different priorities. That, of course, is the value of a synthesis: it helps to define what is relevant, and in so doing, it modifies the representations tied to each source of information to achieve a representation of the situation that is both more focused and more comprehensive.
School-based information on Graeme and his family
Graeme was the only child of a single mother who worked in the fashion industry. His father had left the family when Graeme was very young. Although Graeme continued to have contact with his father, the relationship between his parents was strained and contact was irregular. When he was 14 years old, Graeme was diagnosed with autism.
The early years
Early observations at the age of 3–4 years
When Graeme entered school at 3 years of age, his teachers noted that he was disruptive and his behaviour prevented both his learning and that of other children. He frequently challenged the rules and routines. For example, he was usually the last to sit down at ‘carpet time’ and often refused to tidy up. He found communicating with the other children difficult, insisted on his own way in play and could be physically aggressive with his peers. He preferred the attention of adults and was mature in conversations with them. Graeme not only seemed confident and self-assured but also said things like ‘I’m a horrible little boy’.
Graeme was particularly interested in his appearance; his hair was fashionably gelled and he spent time in front of the mirror checking it. He wore brand name clothes instead of the school uniform and was keen to announce the ‘labels’, for example, asking whether staff liked his new Nike trainers. Staff recalled mum shouting at him ‘all the time’ and experienced her as ‘very negative’ towards him. Mum and the teachers seemed at odds about Graeme.
At age 3, his mum had had Graeme evaluated for possible attention deficit hyperactivity disorder (ADHD); he did not receive any diagnosis.
Observations at 5–7 years
Although Graeme was academically bright, articulate and had a mature vocabulary, he showed limited interest in learning and was easily distracted. At times, he seemed arrogant and argumentative. Graeme found building relationships difficult. For example, the teacher gave the children a pebble to represent themselves by placing it inside a hoop laid on the floor to show where they saw themselves in relation to the teacher and their peers. Most of the children placed their pebbles close to the teacher pebble, but Graeme refused to place his pebble at all and tried to take the hoop away. When his behaviour was unacceptable, Graeme was disciplined by school staff. His mum tried to explain his behaviour, but to the teachers this seemed like excuses or blaming others.
Graeme’s mother sought help for her son from many professionals. When he was 5, with mum’s consent, the school employed a counsellor so that Graeme could discuss his difficulties with a neutral, supportive person who would help him to make sense of his situation and manage his behaviour. The counsellor noted that Graeme was preoccupied with not seeing his father, difficulties with his mother and conflict with peers. Although this counselling continued until he was 11, Graeme’s behaviour did not improve; indeed, it deteriorated.
When Graeme was 5.5 years old, he and his mum participated in research on attachment in the school years (Crittenden, Robson, Tooby, & Fleming, 2017). A Preschool Assessment of Attachment (PAA; Crittenden, 1992) was video-recorded, then 6 months later, when Graeme was turning 6, he was given a School-age Assessment of Attachment (SAA; Crittenden, 2009) and his mother received an Adult Attachment Interview (AAI, George, Kaplan, & Main, 1986). These assessments were coded and classified over the next 3 years (see the next section).
Middle childhood and adolescence
Problems at school
Graeme’s development perplexed his teachers: his frequent disruptions seemed defiant, he was academically bright, and his peers described him both as ‘one of the popular boys’ and as ‘a bully’. Although counselling continued, he had no diagnosis. Once when mum went abroad for work, Graeme became very difficult to manage. School staff felt that his mum did not understand that parental absence could affect children emotionally. The onset of puberty seemed to have heightened Graeme’s problems, but it was unclear why.
DMM-informed treatment
When he was 11, Graeme was referred for mental health treatment because of his low mood and self-harm (concealed scratching of his arms). When his DMM-trained therapist reviewed the classified AAI and SAA, she recognized that both Graeme and his mum had been pulled into their mothers’ marital struggles and lost contact with their fathers. Consequently, she decided to see mum and Graeme separately, but to work with both about disarming the trap of triangulation, by adding complexity to the psychological short-cut of ‘good mum/bad dad’.
A crucial aspect of this work was the therapist’s appreciation of mum’s perspective and her effort to help her son. Rather than beginning with changes the mum should make, the therapist began in mum’s zone of proximal development: her grievances about being scrutinized by the school and her desire to find help for her son. For mum, discovering the ongoing ‘triangulation’ in her childhood family was painful, as was acknowledging her current fear of her mother’s rejection if she re-connected with her father. Nevertheless, she set about repairing the relationship with her father, including letting Graeme get to know his grandfather. As mum was beginning to empathize with her son’s similar predicament, the therapist began working directly with Graeme who used his sessions to express his despondency at wanting both parents, needing to support his mother when she was angry with his father and his desire to see his father. The result of these parallel processes was a reduction in Graeme’s explosive behaviour, at both home and school, and fewer incidents of self-harm. They were just beginning to think about Graeme’s father and Graeme’s fear of rejection when the therapist changed jobs.
The professionals who took over did not understand the formulation around triangulation. Instead, they found Graeme’s mother difficult to work with and sided with his father – without recognizing that they were unwittingly reactivating the triangulating process of ‘divide and lose’. Graeme’s relationship with his mother broke down, he moved to his father’s home and was encouraged not to have contact with his mother. Graeme’s father was hesitant to take Graeme because he was a recovering alcoholic and unsure of his competence as a parent. Initially, Graeme was relieved to be with his father and free of the conflict with his mother, but within weeks he was running back and forth between households. Once again, he was caught up in the animosity between his parents and had no idea what to do about it. His distress spilled out in unacceptable ways. For example, he assaulted a football team mate, resulting in the boy going to hospital.
The current situation
At 15 years, Graeme was living with his mother, having recently received a diagnosis of autistic spectrum disorder. Mum’s relationship with his father was volatile, and periodically she would stop Graeme from seeing him. Mum referred to Graeme as her ‘little mate’ and talked with him in detail about the disputes with his father.
We wondered whether puberty made it more difficult for mum to separate her feelings about men from her feelings about Graeme.
Assessment-based information
Hypotheses
Based on the review of the literature on the causes of autism (Crittenden, this issue), we viewed the assessments of attachment again, specifically to explore three hypotheses:
In the PAA, (a) Graeme’s mother will use closed body positions, will not ‘shadow’ Graeme’s movements and will not look at him when he approaches her; (b) Graeme will approach his mother without achieving contact; and (c) Graeme will use a compulsive Type A self-protective strategy with her.
In the SAA, Graeme (a) will not talk about negative affect and (b) will use a compulsive Type A strategy of relying upon only himself and (c) will show pervasive sadness or futility. (d) When aroused, Graeme will use rigid compulsive procedures to maintain inhibition, but (e) under intense arousal, there might be intrusions of negative affect. (f) Graeme will experience himself as bad.
In her AAI, Graeme’s mother will have (a) a Type A strategy, (b) evidence of psychological trauma and triangulated attachments in childhood and (c) possibly mild depression.
Assessments of attachment are particularly suited to testing these hypotheses because they use mild danger to elicit respondents’ protective strategies. For parents, it is particularly useful to compare child-protective and self-protective strategies.
The assessments of attachment
Graeme’s PAA
The PAA procedure was a standard Strange Situation consisting of eight 3-minute episodes: entry of child and mother, mother and child with toys, arrival of an unknown woman (the ‘stranger’), departure of the mother on the signal of a knock, mother’s first return (and departure of the stranger), mother’s second departure leaving the child alone, the stranger’s return and the second return of the mother (and departure of the stranger). Graeme’s PAA was classified as compulsively caregiving (A3) to his mother. We reviewed the PAA, noting the following:
Graeme’s caregiving strategy. Upon entering the room, Graeme sang to himself, then rocked and fed a doll, showing it to his mum and saying, ‘That’s like me’. We interpreted that he wanted to receive caregiving. He then brought dishes of pretend food to his mother. When they heard the knock, his mum set the dishes on the floor. Graeme said, ‘No, don’t!’, and she put the dishes on her chair and left. While she was gone, Graeme built her a castle, saying she was ‘the new king and I will make her a castle with defensive walls and a mote’. When she returned, he directed her to her chair and offered her tea. He then sought her approval of the castle, calling her ‘the new king’. She did not seem to understand; instead, she sat doubled over (see photograph 3), watching him attentively. On hearing the second knock, Graeme went to open the door for his mum. She told him to return and ‘Sit nice’. He did and played alone without evidence of distress. When the stranger entered, Graeme explained that his mum ‘has a sore tummy’; this suggested that he had read her body posture. In all of Graeme’s many cheerfully caregiving approaches to his mother, his eyes were downcast and he and his mum did not look at each other. When frustrated, he did not seek help.
Mum’s behaviour. Graeme’s mother initially sat with closed legs, hands folded in her lap (over her genitals); at other times, she crossed her legs, tucking her hands between her thighs or wrapped her arms around herself and leaned forward, as if in pain (see Photographs 1, 2 and 3). She sat still, watching Graeme throughout, but they never looked at each other and her body never had an open position. She smiled in a warm way, but without face-to-face contact.
Graeme with the stranger. When the stranger entered, Graeme did not answer her questions and turned his back on both adults. While mum and the stranger chatted, Graeme ‘marched’ between them and then explosively kicked the football aggressively around the room. Then he offered the stranger some toys.
Overall, Graeme used extreme caregiving to his mum, with bits of self-reliance, as his protective strategy. In addition, he used feminine caregiving toys (rather than the neutral doctor’s kit), associated himself with a girl doll and attended closely to his mum’s postural gestures. The PAA supported our expectations of (a) mum’s closed body position, failure to ‘shadow’ Graeme’s movements and lack of postural or facial welcoming, and (b) Graeme’s turning away when approaching and use of a compulsive Type A strategy. In addition, Graeme seemed almost to have ‘an intrusion of anger’ with the football; this seemed to fit the connection between autism and psychosis (see Part 1 of this paper). Compared to other A3 strategies displayed by other children, Graeme’s strategy was quite extreme.
Graeme’s SAA
The SAA consists of seven picture cards to which children are requested to tell a fantasy story and then a recalled episode. Table 1 presents a summary of Graeme’s stories, card by card. Graeme told only one story about himself – on Card 1 where he confused the boy with himself; this is consistent with Just, Keller, Malave, Kana, and Varma’s (2012) finding that children with autism do not represent themselves neurologically in social situations. Thereafter, Graeme spoke only about the boy, but became increasingly agitated (as do children with ADHD, see Part 1 of this paper) until, on the final card, when the boy was happy that the mum died, Graeme had an ‘intrusion of forbidden negative affect’. The initial confusion of self and ‘the boy’ combined with Graeme’s arousal during the fantasy stories permits us to attribute aspects of the fantasy stories to Graeme, albeit without knowing exactly what is true. Put another way, Graeme displaced his negative feelings and experiences onto ‘the boy’ and omitted himself almost entirely. Despite being distressed, Graeme tried to obey, distracted himself by flapping the cards, was pedantic and concrete and had ‘the boy’ rely almost entirely on himself. Graeme did not respond to empathy from the interviewer. A significant thread running through the SAA was that the boy feared rejection.
Summary of Graeme’s 14 SAA fantasy stories and recalled episodes.
SAA: school-aged assessment of attachment.
Graeme’s protective strategy was classified as compulsive compliant (A4) with emerging failed self-reliance (A6), partial depression and a verbal intrusion of (dis)inhibited negative affect. His agitation and repetitive, disruptive behaviour occurred when the questions touched upon rejection. Stories about marital conflict and the expelled father suggested psychological trauma.
Compared to the PAA 6 months earlier, the SAA provided detail regarding the threats of rejection and marital conflict, and revealed Graeme’s failed attempt to survive without parental support. The SAA was generally consistent with the hypotheses, but instead of portraying himself as bad, Graeme omitted himself, as if he had no self-representation at all. Like the Tomm’s SAA (Part 1 of this paper), Graeme’s SAA was both extreme and unusual.
Graeme’s mother’s AAI
The AAI consists of a defined series of questions about childhood relationships and experiences, followed by questions that ask the speaker to consider the meaning of these in adulthood. The analysis of the AAI addresses both the childhood history and implicit information drawn from how the speaker’s language is constructed, that is, the discourse. Graeme’s mother’s AAI was notable for its complaining quality and the repetition of a few trivial complaints (e.g., ‘He would have a proper Coke, but we would have a cheap coke’). On the whole, however, a professional who was not trained as a coder would not find this AAI particularly remarkable.
Graeme’s mother introduced her parents’ ‘split-up’ in her first response and cast most of her responses in comparative terms that idealized her mother and derogated her father. She did not report experiencing any dangerous events, but noted several times that separating from her parents for school, babysitting or even at night was extremely distressing. She recalled, ‘they must have been arguing or something, but I can just remember that tha the that’s the only bit I can remember. I just remember my mum crying’. Much later she said, ‘but obviously, it upsets ya and you’re gutted about it’. We noted Graeme’s mother’s collusion with her mum and the present tense of ‘upsets’. Graeme’s mother also recalled having been ‘quite close with a guy’ her mum was living with, but they ‘split up’; this was said with considerable dysfluence. Later she concluded, ‘Yeh, yeh, the marriage it jus, I don’t know, it just makes me wary’.
In terms of discourse, Graeme’s mother (a) had many unacknowledged contradictions, often in close juxtaposition; (b) spoke in absolute terms (e.g. always, never); (c) connected ideas with ‘but’; and (d) used reflexive questions to confirm that everyone would act as she did – wouldn’t they? Together, these discourse markers suggest unacknowledged internal conflict. ‘So …’ was used to omit her own contributions to the events: ‘I can remember goi-, my mum taking me to nursery erm erm and erm as she was leaving me. I was crying because I didn’t want to go to go and bust my chin so she had to come back for me ha ha. (What happened then?) I don’t remember anything other than the actual falling and me mum having to come back for me. So …’. The transformation from ‘going’ to ‘taking’ shifts volition from herself to her mum, whereas the ‘so’ implies a relation between her falling and her mother returning. She also ‘hated’ to have to wait outside her parents’ bedroom door in the morning for them to wake up. She chose five positive words to describe her relationship with her mother (loving, caring, special, friends, there for each other), but did not have episodic evidence for any of them. For her father, she initially ran on at length about his not giving her food that she liked but her mother did and then, when brought back on topic, said ‘not close’ and ‘distant’. For distant, she said, ‘Jus just all the time. I never go and sit with my dad for a hug because …. It just wasn’t like that with my dad. With my mum, it was so …’. This is one of several examples in which she confuses rejecting her father with being rejected by him. This example had the absolute ‘never’, present tense ‘go’ and passive ‘so’; they suggest confusion of quality, time and responsibility. There were also indications of slippage from her father to Graeme’s father (‘If if Graeme has a dad like my dad he y you know th they know, don’t they?’). At the beginning of the AAI, she included Graeme as part of ‘we’ when she discussed her childhood relationship with her grandparents. She said that her goal as a parent was to ensure that Graeme did not feel rejected as she had.
Graeme’s mother’s AAI was classified as idealizing her mother (A1) and angrily derogating her father (C5) in a triangulating way (Δ) that pitted her and her mother against her father (A1M C5F Δ). Part of this conflictual triadic strategy involved the logical lacunae of denying (a) her mother’s responsibility in the divorce, (b) her father’s positive qualities (that she discussed and dismissed) and (c) her own feelings of loss. At the time of the AAI, she still sided with her mother against her father. The AAI supported our hypotheses, drawn from the literature review and observation of archival cases, and added the ideas of triangulation which seemed consistent with her postural ambivalence to Graeme in the PAA and gender confusion which was consistent with Graeme’s play in the PAA.
Conclusions about the assessments of attachment
Taken together, the assessments of attachment confirmed our expectation of the importance of postural/gestural communication from mothers of children diagnosed with autism. They also suggested that male gender might be an issue. The PAA demonstrated Graeme’s intense connection with and sensitivity to his mother. The SAA and AAI demonstrated the transgenerational experience of paternal rejection, including rejection by the mum of her father for her self-protection. We also noted that Graeme’s assessments stood out as atypical, whereas the mother’s AAI did not – until it was coded by a properly trained coder. Finally, it was clear in all of the assessments that both mother and son felt bad about themselves and were trying, in extreme ways, to manage their relationships as best they could.
An Family Functional Formulation for a case of autism
We opened with Graeme’s mother’s challenge: ‘I put it to you that there were plenty of opportunities for things to be done differently’. We closed the introduction by asking whether there were fundamental processes that could have led to an alternative route forward, by-passing a decade of frustration that ended only with a diagnosis and not a solution.
To address that question, we combined the conclusions of the (a) review of the literature on, and archived cases of, autism with (b) Graeme’s developmental history and (c) the formal assessments of attachment to generate a Family Functional Formulation (FFF) of one case of autism. Our goal was to integrate information in a reflective process that might suggest ways to understand Graeme’s behaviour and new directions for clinical work.
The FFF and fundamental processes
Our formulation of Graeme and his mother (plus Graeme’s father and maternal grandparents) fit our hypothesis from Part 1 of this article of a multigenerational process (both vertically and laterally), with psychological trauma in the mother’s childhood, issues of sexuality, and hidden processes, in this case, triangulation across two generations. We also found support for the notions of bodily communication replacing visual communication, Graeme using a caregiving strategy with his mum while beginning to develop a compulsively self-reliant strategy, and his mum both protecting him with warmth and protecting herself from him with subtle signals of rejection. Mum’s mixed feelings about her father and partner were seemed related to Graeme’s gender confusion (e.g. being like a girl doll and later being a hyper-masculine athlete, see below) and his intrusions of negative affect. These seemed to be parts of the complex process that maintained Graeme’s strategy of inhibition around mum’s ambivalence regarding males. It is important to state clearly that a case study cannot establish causal relations among the events, people and conditions and that none of these conditions taken alone suggests risk for autism. Only their unpredictable systemic and development co-occurrence was associated with Graeme’s diagnosis of autism.
As we reflected on this case, we were struck by how each additional source of information changed the representation of the problem and the implications for treatment. Each representation had seemed complete, but other information showed it to be incomplete. Each change added complexity to the ultimate representation. Based on his early school experience, Graeme’s mum had Graeme evaluated for ADHD; she conceptualized the problem as one person’s disorder. The school responded by offering supportive counselling to reduce his inappropriate classroom behaviour; this was an interpersonal solution to one person’s disorder. Once the attachment classifications were known, the treatment focus shifted to Graeme’s mother and disarming her triangulated relationships across two generations. The subtle gestural/bodily communication between Graeme and his mother was not identified until we reviewed the literature, archived cases, and Graeme’s PAA; without all of that, the process through which both their mutual love and fear of rejection were transmitted could not be discerned. One fundamental process, in other words, was conceptualizing behavioural problems interpersonally, using many sources of information.
Crucially, the assessments of attachment identified psychological short-cuts (e.g. idealization and derogation) made by Graeme and his mum. These short-cuts made complex situations appear simpler than they were, thus making decisions seem easy. Developmentally, children use short-cuts when faced with more complexity than they can manage. Sometimes these short-cuts are carried into adulthood where they create new problems with marriage and raising children – as they did for Graeme’s mother. Professionals also use short-cuts, particularly when they lack information about the family. Psychiatric diagnoses are short-cuts that omit information about the interpersonal conditions and processes underlying symptom behaviour. In this case, the relevant information was the mother’s psychological history of her parents’ marital discord and her own triangulation into it. Notably, home visits and discussions with the mother would not have revealed this information because it was implicit. A second important process may be the use of psychological short-cuts.
Triangulation is a particularly difficult short-cut to discern and disarm. Triangulation is not obvious to parents and, therefore, not something they can report (Dallos, Lakus, Cahart, & McKenzie, 2016). In Graeme’s case, neither he nor his mother was aware of it or its implications. Triangulation around ‘bad’ fathers may have further jeopardized Graeme’s relationship with his mum – because he too was male. With so much unspoken complexity and ambivalence, the cycle of interpersonal failures becomes hard to break, with both mother and son contributing unintentionally. Professionals too entered the fray unknowingly – on the side of the less well-known father against a mum who irritated them. Triangles seem to have an affinity for replicating themselves in new contexts. Triangulation constitutes a third fundamental process that, if revealed, might have changed the course of treatment.
What does a diagnosis of autism mean? Returning to ‘autism’ as a formulation, the diagnosis satisfied Graeme’s mother because it seemed to vindicate her and puzzled the professionals because Graeme’s behaviour did not fit their notion of autism. As a heterogeneous disorder, autism probably reflects many developmental pathways that share only the three basic symptoms: extreme difficulty with relationships, withdrawal from intimacy and repetitive behaviours. For professionals, the diagnosis made Graeme eligible for special services while also lowering their expectations of his potential for normal functioning and diverting attention from his family context.
It seems important to ask what being diagnosed with autism meant to Graeme. Soon after diagnosis, Graeme moved to his father’s home and lost touch with his mum. He spent a lot of time at the gym doing body building with his father, hoping to be selected by a football team. He was excluded from school several times because he was at the gym during school hours. He continued to have conflict with peers (e.g. pushing a friend into the path of an on-coming car). He attributed this and other events to his autism, and his friends generally excused himfor that reason. Nevertheless, he was passed over for a national football team because of his overly aggressive behaviour. We note both his lack of taking responsibility for his actions (because ‘the diagnosis did it’) and his emphasis on strong masculine behaviour (Figure 1).
Mother’s closed body position.
What does our FFF mean? We think our formulation offers an understanding of how Graeme’s behaviour became increasingly maladaptive. It also suggests a therapeutic process through which Graeme can form positive relationships with both his parents and grandparents, his mother can regain access to her father and his mother’s ambivalence about having a male child can be resolved. Moreover, all of these outcomes can be achieved without assigning blame and with awareness of everyone’s good intentions. For the school, our FFF permits an early and efficient use of resources and the expectation that, with appropriate family-level treatment, Graeme can lead a normal life.
The school’s perspective – 20/20 hindsight
We would like to close with a quote from the school, written as all reflective learning is, with the advantage of hindsight: In school, our primary focus is the child. Looking back, it is clear that Graeme did communicate clearly his level of distress at not being able to see his father, but we didn’t recognize the significance of building this into our intervention. Did our feeling that Graeme’s difficulties were the result of family dysfunction affect our relationship with his mother, compounding her negative view of her parenting and reducing her attunement to Graeme? We would like to think we treat all parents sensitively, with compassion and without allowing our personal opinions to affect our interactions. However, Graeme’s mum obviously drew a negative impression of educators. Understanding parents’ perspectives now enables us to be better attuned to family needs and to communicate more effectively, so as to discover more effective intervention strategies more quickly. In reflecting on our learning from involvement with Graeme’s family, we are aware of the need for a closely co-ordinated team around the family. Better outcomes might have been achieved with a team that held a deeper, shared understanding of Graeme’s whole family. Of course, we were under-resourced, but in the end, resources were wasted because they were not the services that Graeme needed. Reviewing our experience with Graeme and his family has heightened our awareness of the impact of the early intervention and the power of feeling rejected to hurt everyone.
The reflective process in the school’s response is precisely what can lead to solutions. Particularly important was the educators’ ability to ask questions about themselves and to seek answers in the light of new information. It is in schools such as Graeme’s that new solutions for difficult problems can be found. This is adaptation at its best.
With this in mind, we wonder whether we have all the relevant information now. Is our FFF finished? We think not. We think good clinical work always discovers new questions and refines formulations on the basis of the answers. Our ‘solutions’ led to new questions:
How common is postural/gestural communication in autism – and other disorders?
Do other children with a diagnosis of autism use caregiving strategies?
Do they experience gender confusion?
Is maternal triangulation common among mothers of children with autism?
What is the role of fathers with regard to mothers, wives and children diagnosed with autism?
We hope this case study, including the review of the literature and clinical cases, can form a basis for more methodologically complete research on these fundamental issues that transcend autism per se and address basic adaptive processes.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.