Assessment in Child Psychotherapy

Emanuela Quagliata, Margaret Rustin, Emanuela Quagliata, Margaret Rustin

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367105419
• eBook ISBN:
  9780429911019
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book describes an approach to children and young people who might be helped by child psychotherapy. Attention is paid to factors within the child's personality, to strengths and impediments in the developmental process, and to the family and wider school and community context. Individual chapters address both clinical methods and a variety of clinical problems, including work with very young children and their parents, severe deprivation and family breakdown, developmental delay, and the more serious psychological illnesses of childhood. Assessment in Child Psychotherapy is a significant contribution to all mental health professionals who need to be able to identify the precise nature of a child, adolescent or family's problems and to offer the most appropriate help. Such a book is long overdue. It spans a range of thinking about how best to reach those whose emotional and behavioural difficulties pose challenging questions as to the most suitable forms of treatment.

1

Assessing Children with Communication Disorders

Maria Rhode

The children I shall discuss in this chapter suffer from autistic spectrum disorder, mutism, or a learning disability arising from a pervasive developmental disorder (PDD). I shall not be considering children who stammer, or the psychotic or borderline children discussed by Anne Alvarez (this volume) who may use words in idiosyncratic ways for purposes other than communication. However, some of the points Alvarez makes are highly relevant to the kind of child I shall discuss, such as the importance of assessing the symbolic level at which the child is operating at any moment. This is essential if we are not to misunderstand him, and if we are to be able to phrase our own communications in ways that he can hear.

Autistic spectrum disorder includes children with autism proper and with Asperger’s Syndrome. Children with autism may be completely mute, or may produce language ranging from single words to complete sentences. Sometimes their words are their own; often they are quotations from stories, songs and videos, or they may be echolalic reflections of someone else’s speech (Rhode, 1999). In Asperger’s Syndrome, language is well-developed though it is often used idiosyncratically (see Rustin, 1997; Youell, 1999). According to the criteria of DSM-IV, children with autism must demonstrate Kanner’s (1943) classic triad of impairments: affective, cognitive, and social, which must have been manifest by the age of three. Children with pervasive developmental disorder (PDD) satisfy some of these criteria, but not enough for a diagnosis of autism.

On the face of it, there may not appear to be much in common between a child who, without being a selective mute, cannot speak to unfamiliar adults, and a child with autism who may not speak communicatively even with his parents, and whose communication with himself – his capacity for thought and self-awareness – may appear bizarre or virtually non-existent. However, even the child who suffers from severe or persistent shyness may be showing that he does not expect people to be receptive, or that his internal communication with important figures is not providing him with adequate support and confidence. In my experience, children whose problems with verbal communication play an important part in their referral for assessment usually reveal anxieties characteristic of autistic spectrum disorders – fears of falling, of spilling out, of losing body parts, of burning, freezing, and so on, although there are significant variations in how much of the child’s personality is affected, in how drastic are the coping devices that he has resorted to, and in how far he has been able to develop useful capacities. As Tustin (1981) has pointed out, these are elemental terrors to do with annihilation: what is at issue is the child’s continued existence. Whatever may have contributed to experiences such as these, they can feel impossible to convey in words, and possibly unbearable to the person they are communicated to. Children who live much of their lives in this domain pose a challenge to the therapist’s endurance and emotional resources.

I shall begin with some general considerations concerning communication before discussing findings from work with children with autistic spectrum disorders that have a direct bearing on assessment issues.

Findings from both psychoanalysis and child development research indicate that disorders of verbal communication arise out of a matrix of impaired non-verbal communication. Trevarthen (1993), for example, has documented the minute detail of non-verbal ‘conversations’ between mother and baby. It is out of such experiences of attunement (Stern, 1985) and reciprocity that the child develops the capacity for enjoyable play, joint attention and turn-taking, all essential precursors of speech. The mother’s responses play an essential role in her baby’s development of language (Trevarthen & Marwick, 1986; Papousek, 1992). Work such as this links readily with contemporary psychoanalytic approaches (Alvarez, 1992).

According to Bion’s theory of alpha-function (Bion, 1962), the child’s development of verbal thought is rooted in the mother’s receptivity to her baby’s primitive communications of feeling and to her capacity for reverie. Bion emphasised that speech could by no means be automatically equated with communication: words could just as well be used to evacuate disturbing emotion or to act upon another person. Meltzer (1975) amplified this in his discussion of ‘Mutism in autism and schizophrenia’. He proposed that five factors in language function underlay the use of vocalisation for communicative purposes. These were alpha-function, leading to the formation of dream-thoughts; the presence of internalised ‘speaking objects’, in identification with whom the child could clothe these dream-thoughts in language; the acquisition, during the years when the lalling impulse was strong, of a vocabulary for describing the outside world; the presence in the outside world of human beings with whom the child wished to communicate; and a recognition that these human beings were sufficiently different from the child so that inner processes were not automatically known to them, but required vocalisation. All these formulations implicitly point up the importance for the development of language of the child’s relationship to the internal parental couple. As early as 1928, Melanie Klein had pointed out that verbal communication between the parents could be the object of Oedipal jealousy, while Segal’s paper on symbol formation (Segal, 1957), focusing as it did on the importance of working through the depressive position in relation to a whole object, implied the centrality of the Oedipal constellation. More recently, this has been emphasised by Britton in relation to the development of the capacity for sanity, verbal thought and self-reflection (Britton, 1989 and 1998).

All this implies that when we meet a child with a communication disorder, we may reasonably see this as the expression of something very fundamental about the child’s relationships with its caregivers. It also makes it understandable that, in treating or assessing a child whose presenting problem concerns verbal communication, we may find ourselves experiencing powerful emotions in the countertransference. Often these may turn out to be our best guide. However, they require careful thought if they are not to lead to ill-considered and inappropriate action, such as becoming exclusively identified with the viewpoint of one member of the family. I shall return to this later.

THE ASSESSMENT OF CHILDREN WITH AUTISTIC SPECTRUM DISORDER

Psychoanalytically-based treatment of children with autistic spectrum disorder is still highly controversial. Bettelheim’s blanket endorsement (1967) of Kanner’s claim that autism was caused by ‘refrigerator mothers’ soon provoked an indignant backlash: parents are still warned that ‘psychotherapists say it’s the parents’ fault’ (see Arons & Gittens, 1999). I have heard this view attributed to Frances Tustin, in spite of her explicit statements that the parents she had known professionally were sensitive and devoted, and inspired compassion and therapeutic ambition (Tustin, 1972, 1994). Many psychiatrists and psychologists will state categorically that autism is caused by a brain abnormality – as indeed it may well be (Tustin, 1984; Grotstein, 1997; Shuttleworth, 1999). These professionals feel that psychotherapy is therefore contraindicated, and that the only useful approach is to find an appropriate educational placement. However, some autistic children have responded favourably to treatment (Tustin, 1972, 1981, 1986, 1990; Meltzer et al., 1975; Alvarez, 1992; Haag, 1997; Alvarez & Reid, 1999).

In these circumstances, therapy can easily be broken off at a critical juncture. It is all the more important to invest time during the assessment in order to be as sure as reasonably possible that parents understand what treatment means and are serious about wishing to support it. It is a sad fact that responsive children do not necessarily have parents to whom a psychoanalytic way of working makes sense, and vice versa. Besides, parents are awkwardly placed: they are bound to be aware that serious disagreement as to the value of psychotherapy exists among professionals. Such disagreement is doubly difficult for parents whose own co-operative partnership may well be under severe stress for reasons which I shall return to. My own view is that it is best to confront this difficulty directly. I say to parents that, as they probably know, different views exist about the aetiology and treatment of autistic spectrum disorders, and that, as far as I am concerned, at present far too little is known for me to assert that there is no truth in an organicist position. (Indeed, recent research on the relationship between affect and brain structure [Perry et al, 1995; Schore, 1994] suggests that the stark dichotomy between organicist and psychodynamic approaches may prove to be a false one.) However, even committed organicists would usually agree that a child with a neurological disorder will also have emotional problems, some of them caused by his disability (Sinason, 1986). This means that psychotherapy may remove emotional obstacles which could otherwise prevent the child from reaching whatever his ceiling might be. I find that parents tend to respond well to this way of putting things, since they do not feel that they are being pressurised into ‘choosing between Mummy and Daddy’ as far as different professional approaches are concerned. I also stress that I am happy to co-operate with professionals who may have a different outlook. As far as the question of blaming parents is concerned, I have found it useful to quote how one school put it: ‘If you had a child who was blind, you wouldn’t blame yourselves for his condition, but you would know that how you responded to it would make all the difference.’

The fact remains that some children with autistic spectrum disorder respond to treatment and that others do not. When they do, it is indescribably rewarding. Many therapists will agree that getting through to a child with autism makes them feel privileged to be involved in such work, and that love and hope can flower in ways that are humbling and awe-inspiring, and difficult to describe without sounding self-idealising and sentimental. On the other hand, in the long stretches of time when a child does not respond the therapist may be filled with doubt and self-doubt, with feelings of chaos, madness and hopelessness, and a dreadful apprehension of the power of destructiveness, the waste of potential, and the unactualised possibilities in human life. The therapist has to bear not knowing whether feelings of despair are a communication or simply realistic. A child may begin treatment at three and be little better after years of intensive work. Feeling able to understand and learn from the child is not a reliable guide: it tells one nothing about the child’s capacity to learn from the therapy.

With autistic spectrum disorders, it is therefore essential to distinguish between two different aspects of the assessment process. One aspect concerns the attempt to understand something of the problem, both in its present form and in the way it has evolved, so as to be able to make a tentative formulation. The other aspect is about forming an opinion concerning the child’s responsiveness to this particular therapeutic approach, and about the degree to which the parents feel that this way of working makes sense to them and that they can support it. In practice, this second aspect may be the crucial one in deciding what sort of treatment to offer, and there may be less overlap between these two aspects than is the case in the assessment of other kinds of difficulty. This is partly because one consequence of communication problems within the family is that some parents may find it difficult to remember or to talk about events or feelings that turn out to have been crucially important. The picture given in the course of an initial history may be dramatically modified by facts which sometimes emerge only after years of work with the family.

From Frances Tustin onwards, workers have attempted to delineate different types of autism (see also Wing and Attwood, 1987, for a psychiatrically-based approach). Tustin (1972) distinguished between the shell-type children described by Kanner and confusionally entangled children; later (Tustin, 1981) she wrote about ‘segmented autism’, in which different aspects of the child’s personality and capacities are separately encapsulated and re-assembled. Those children whom in her first book (Tustin, 1972) she called RSA (Reactive Secondary Autism) probably correspond to the group whom she later described (Tustin, 1990) as manifesting signs of schizophrenia once the autism which had previously kept this in check had been ameliorated. Alvarez (1992, 1999a) has emphasised the importance of deficit, particularly in relation to a certain type of extremely passive child with autism, who appears to have much less strength at his disposal than does the encapsulated Kanner-type child. Reid (1999c) has contrasted the traumatised child who responds by autistic withdrawal which she relates to post-traumatic stress disorder, and the perverse child who derives pleasure from his autistic coping strategies. Alvarez and Reid (1999) have stressed the importance of the individual child’s personality, and have proposed various sub-sub-groups which may require specific technical modifications (p. 9).

In my experience, it can be unwise to try to predict who may benefit by treatment on the basis of which type of autism they seem to exemplify. The argument is convincing that someone who is excessively passive, or who derives pleasure from their autistic coping devices, may prove difficult to help. Again, one might reasonably expect to run into a ceiling in complicated situations where the child’s problem fulfils a function in the family dynamics, or simply where treatment has begun too late. On the other hand, I have myself seen rewarding results with a child who did not begin once-weekly treatment until the age of nine, whereas another child who came three times a week from the age of three years and ten months changed relatively little (Rhode, 1996). Whereas the nine-year-old employed autistic manoeuvres in the service of maintaining control over me as an idealised figure, the three-year-old rejected all contact for fear of being engulfed or of being rendered soft and vulnerable. In other words, in these cases at least the precipitating factor of major trauma seemed relatively unimportant. So did the phantasy content of the children’s material, which was in fact strikingly similar. What mattered was whether the child had an idea of a good contact, which could be built on.

In practice, I feel that probably the most important single factor as far as the child is concerned – apart from the question of whether the family can support treatment – is the degree of warmth that he inspires. This factor is also crucial in psychotherapy with deprived children (Boston & Szur, 1983), and can prove to be a surprisingly sophisticated guide.

In one assessment which I carried out jointly with a colleague, I found myself not warming at all to four-year-old John during the joint assessment sessions. This was not because of the way he climbed over me as though I did not exist – that is common enough, and the parents had told us how unable they felt to set limits. It was more that he seemed to convey a quality of mechanical inexorability. In the individual sessions, however, my colleague made a good contact, and was touched when John said about a helicopter, ‘It’s looking for a place to land’. In the course of therapy with my colleague, John made extremely gratifying improvements, to the extent of managing reasonably well in mainstream school. However, after having reached a point of genuine, warm and co-operative work, he seemed for a while to be pulled away and out of contact. On one memorable occasion, after he had engaged in some valuable communicative play, he turned to address a toy lying on the floor: ‘I’m sorry I spoke in words’ (Shulman, 1997). The toy at that moment appeared to represent whatever it was that was interfering with a good link between John and other people. In retrospect, I think that in the assessment sessions he divided aspects of his personality between me and my colleague, and that our combined response to him gave the most useful indication of how things were to go.

Reid has recently described in detail the method of assessing children with autistic spectrum disorder and their families which she has developed in the context of the Tavistock Autism Workshop (Reid, 1999ab). She emphasises the importance of thinking of the child within his family, and of opening oneself to the experience of receiving child and family together. This experience, which can often make the therapist feel de-skilled, ignored or taken over, can provide information about the impact of such a child on his family. Reid stresses the importance of continuing these therapeutic assessments over a considerable period of time. This means that the assessment of a child’s ability to benefit from therapy and his parents’ ability to support it will be based on whether change has actually taken place. If the child has made improvements in emotional contact, shared attention and verbalisation, this is something that can be pointed to in discussing with the parents why he might be expected to benefit from further work. Reid emphasises that she does not on the whole proceed to the stage of an individual assessment until she has had some success in making links between the child and his parents. This is done by commenting on the child’s play or other behaviour in a way that is geared towards bringing him and his parents closer together. She encourages the parents to carry on paying attention to the child by asking them to keep a diary, which is discussed at the next appointment. This gives the parents the message that their child’s behaviour is meaningful, that they are themselves able to get closer to him by means of observation, and also that they have a vital part to play in any therapeutic process. As a ru...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• Introduction
• 1. Assessing Children with Communication Disorders
• 2. Borderline Children: Differentiating Disturbance and Deficit
• 3. Severe Eating Difficulties: Attacks on Life
• 4. What Follows Family Breakdown? Assessing Children who Have Experienced Deprivation, Trauma and Multiple Loss
• 5. Assessing Sexually Abused Children
• 6. An Under Fives’ Counselling Service and its Relation to Questions of Assessment
• 7. Family Explorations
• 9. Assessing the Risk of Self Harm in Adolescents: A Psychoanalytical Perspective
• Subject Index
• Index of Names