Clinical Child Psychology and Psychiatry

Autism is a psychiatric disorder of unknown aetiology. In this article, the literature on genetic, neurological, psychological, relational and cultural causes of autism is reviewed, beginning with the 2014 review of Crittenden, Dallos, Landini et al. (pp. 64–70) up to and including recent publications in 2017. Some of the findings were unexpected; others led to new questions. The unexpected findings were the minimal contribution of genes to autism, the extremely evident neurological differences, the interpersonal quality of the psychological findings (that lacked evidence of parents’ behaviour), the relational evidence that mothers’ childhood trauma, perinatal stress and marital stress increased the risk of autism, and the reciprocal relation between funding for treatment of autism and diagnoses of autism. Notably, there was an abundance of genetic studies, numerous neurological studies and only scattered psychological, relational and cultural studies, thus rendering those findings speculative. The new questions included whether mothers used postural/gestural signs to signal their children to maintain distance and whether mothers experienced wariness of males as a result of childhood trauma, with their sons possibly experiencing gender confusion. Following the literature review, a small archival set of video-recorded and transcribed assessments of attachment of cases of autism were examined for evidence to corroborate or refute the psychological and relational findings of the literature review. The findings were striking in their support of mothers’ use of postural/gestural communication regarding distance, children’s close attention to mothers’ bodily signals, without looking at mothers’ face, mothers’ greater comfort when they approached their sons than when their sons approached them, one boy’s lack of verbal self-representation and mothers’ childhood triangulation. These became hypotheses regarding what to look for in Part 2 of this article, a prospective, 12-year case study.

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.

Attachment theory has developed over many decades - and continues to develop. Its roots lie in several seminal publications of John Bowlby (the basis of attachment theory) and Mary D. S. Ainsworth (the notion of individual differences in attachment). This paper identifies the prescient contributions of these early publications and two processes (a long-term dialogue and reflection on discrepancy) that underlay emergent theory. Because I was a student of Ainsworth when both attachment theory and individual differences in attachment organization were becoming better known, I offer some of my recollections of that period, suggesting how that period may have affected current work in attachment.

Adolescent self-harm is prevalent in residential and secure care and is the cause of distress to those harming themselves, to the staff caring for them and for other young people living with them. This article sought service user views on what staff supports were effective and what were counter-productive in order to improve the care offered to young people. Seven young people living in residential or secure care were interviewed. Thematic analysis was used to elicit key themes. Global themes of safety and care were elicited. The young people understood and accepted that the role of staff was to provide these. Within these themes, they noted numerous responses that had both helpful and unhelpful effects, including increased observation, removal of means and extra collaborative support. Service users made numerous recommendations to increase the helpful effects of staff support. Young people provided informed and helpful guidance on how best to care for them. Their views can help mental health professionals and care staff increase their helpful responses making them more effective and less counter-productive. This study is a rare representation of the views of young people in residential and secure care and how to respond to their self-harm behaviour.

This study examined the sequential relations among three pertinent variables in child psychotherapy: therapeutic alliance (TA) (including ruptures and repairs), autism symptoms, and adherence to child-centered play therapy (CCPT) process. A 2-year CCPT of a 6-year-old Caucasian boy diagnosed with autism spectrum disorder was conducted weekly with two doctoral-student therapists, working consecutively for 1 year each, in a university-based community mental-health clinic. Sessions were video-recorded and coded using the Child Psychotherapy Process Q-Set (CPQ), a measure of the TA, and an autism symptom measure. Sequential relations among these variables were examined using simulation modeling analysis (SMA). In Therapist 1’s treatment, unexpectedly, autism symptoms decreased three sessions after a rupture occurred in the therapeutic dyad. In Therapist 2’s treatment, adherence to CCPT process increased 2 weeks after a repair occurred in the therapeutic dyad. The TA decreased 1 week after autism symptoms increased. Finally, adherence to CCPT process decreased 1 week after autism symptoms increased. The authors concluded that (1) sequential relations differ by therapist even though the child remains constant, (2) therapeutic ruptures can have an unexpected effect on autism symptoms, and (3) changes in autism symptoms can precede as well as follow changes in process variables.

This article describes the contribution of video interaction guidance (VIG) to the development of infant and parental and VIG practitioners’ mental health and well-being. The theoretical core of VIG was depicted in terms of concepts such as intersubjectivity, attunement and mediated learning. The way the VIG principles alongside the underpinning values and beliefs promote a process of attunement between parent and infant, the VIG practitioner and parent, and the VIG practitioner and supervisor is described. This article also describes some of the evidence about the effectiveness of video feedback techniques more generally and the way in which the underpinning theory of change enables VIG to target key ports of entry in terms of areas that have been highlighted by numerous epidemiological studies as being important in terms of supporting or derailing infant attachment security. A case study is used to demonstrate the way in which VIG can be integrated within broader therapeutic approaches such as parent–infant psychotherapy to support the interaction of parents who have been deeply traumatised in childhood. It also demonstrates how the parallel process of practitioner ‘attunement’ to mother is key to the mother’s recovery and her new ability to form attuned relationships herself with her children and other adults.