Sensory-Based Relational Art Therapy Approach (S-BRATA)

Supporting Psycho-Emotional Needs in Children with Autism

Huma Durrani

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000296877
• Edition: 1
• Topic: Psicología
• Subtopic: Trastornos del espectro autista

This book bridges art therapy practice and research by presenting sensory-based relational art therapy approach (S-BRATA), a clinically tested framework for working with children with autism spectrum disorder (ASD) that explicitly addresses sensory dysfunction and its impact on impaired attachment.

The author shows how art therapy can facilitate attachment while addressing sensory problems that might underlie impaired attachment shifting the focus from the behavioral to the emotional development of the child with autism. The book additionally challenges traditional aspects of art therapy practice, particularly the focus on the relational aspect of the intervention and not the art product. Not restrictive or prescriptive and with the potential to be adapted to other interventions, S-BRATA provides an explicit framework for doing art therapy with children on the spectrum that opens the scope of art therapy practice and encourages flexibility and adaptation.

Clinicians, students, and parents alike will benefit from the text's clear outline for relational development with individuals on the spectrum and its emphasis on the importance of the psycho-emotional health of a child with ASD.

Part I

Autism, Attachment and Sensory Integration Dysfunction

1 Raising a Child on the Spectrum

A Brief History of ASD and Traditional Treatments

In 1943, a physician at John Hopkins University, Leo Kanner, was one of the first to identify autism or infantile autism, after observing children who shared a pattern of symptoms such as the need for sameness and solitude. Based on his observation, Kanner claimed that these children had “inborn autistic disturbances of affective contact,” implying that they lacked the inherent ability to form relationships (Kanner, 1943, p. 250). Kanner initially leaned toward a biological explanation for autism because, according to him, these children appeared to exhibit their characteristic behaviors from an early age. Later, however, he changed his opinion to take in a psychological perspective that popularised the idea of autism as caused by inadequate parenting and used the term refrigerator mothers to characterise their inability to relate to their children with typical warmth and empathy (Kanner, 1943). The opinion that implicated poor parenting as the cause for autism was further popularised in 1967 by Bruno Bettelheim, an influential psychologist at the University of Chicago. Kanner’s and Bettelheim’s perspective guided the medical profession on autism for a quarter of a century (Grandin & Panek, 2013) and resulted in mothers blaming themselves for the condition of their child. Hans Asperger, who was Kanner’s contemporary, published a paper in German in the 1940s describing a condition he called autistic psychopathology pertaining to children with restricted interests, rigid behaviors and inappropriate social relationships. Asperger’s work was largely ignored, possibly because it was in German and maybe due to intellectual theft, only to receive recognition later when children with autism with strong intellectual ability and verbal language were classified as having Asperger’s Syndrome (Silberman, 2015).

Subsequently, the disciplines of medicine and psychiatry evolved, and the definition and diagnosis of autism changed as the classification of psychiatric illnesses became more precise and ordered. For instance, autism had been confused with schizophrenia early on; the development of a diagnostic checklist of autistic behaviors that did not overlap with those of schizophrenia resulted in a formal diagnosis of the condition with its presenting criteria (Grandin & Panek, 2013).

Experts such as Bernard Rimland, a psychologist and parent of a child with autism; Lorna Wing, a psychiatrist; and Ivar Lovaas, a clinical psychologist contributed significantly toward the understanding and treatment of autism. Wing (1996) revived the work of Asperger and introduced the term Asperger’s Syndrome to identify children on the higher functioning end of the spectrum. In fact, it is Wing (1996) who is credited for identifying autism as a spectrum rather than a differentiated disorder or disorders. Rimland (1964) refuted the myth of the refrigerator mother through his writing, based on observations of his own child, that he believed implicated a neural origin of autism. Rimland’s opinion was widely welcomed by distraught parents who were being blamed for causing autism in their children.

Finally, by the 1990s and early 21st century, the human genome project revolutionised the study of genetics, and in 2007 specific areas of the genome were implicated in the etiology of autism (Grandin & Panek, 2013). Concurrently, a publication in the Lancet of a study that examined whether the measles, mumps and rubella (MMR) vaccine might be a cause of autism gained popularity as a theory among the general public (Wakefield, 1998). This theory continues to be contested as credible, even though the original research study that made a claim has been disproved (Deer, 2011).

Autism spectrum disorder (ASD) is now a singular diagnosis recognised as a continuum of comorbid difficulties with speech and language, social skills, psycho-motor regulation, sensory integration, theory of mind, restricted repetitive behaviors (RRBs) and self-stimulatory behaviors also known as stimming, among others (American Psychiatric Association, 2013). Autism is classified according to severity of scales (levels 1–3) depending on the level of support required for daily functioning, and the diagnosis of Asperger syndrome has been removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). For a diagnosis of autism, the symptoms must be present from an early age even though diagnosis occurs later in life.

According to the most recent statistics (Centres for Disease Control & Prevention, 2019) 1 in 59 children is diagnosed with autism, and boys are four times more likely than girls to have autism. While autism can be diagnosed as early as 2 years of age, most children receive a diagnosis around 4 years old. The prevalence of autism has resulted in a paradigm shift among the supporters of the neurodiversity movement who support the social model of viewing ASD as a natural variation of the human genome as opposed to the medical model that pathologises it as a disability. Champions of the neurodiversity movement denounce interventions that focus on changing autistic behaviors and looking for ways to fix autism. They advocate for accommodation and inclusion of individuals with differences without having to conform to the accepted standards of normality imposed by society.

Most treatments for ASD have focused primarily on modifying behaviors and the teaching of skills driven by the long term objective of enabling individuals with autism to achieve self-dependency. Below is a brief description of some of the traditional approaches that are available for caregivers to choose from once a diagnosis of autism has been made. The list is by no means complete or exhaustive; however, it is indicative of the trend toward targeting the behavioral, communication and skill building needs of the child with autism.

ABA

Lovaas (1987) pioneered the first behavioral intervention called Applied Behavior Analysis (ABA) which is based on the principles of operant conditioning that focus on teaching skills by breaking them into small steps and using a reward, punishment, reinforcement system. ABA is delivered as a one-on-one intensive treatment over 20–40 hours in the week. The progress of the child is recorded and reviewed regularly to make adjustments. ABA has evoked considerable controversy over the years because in its initial form, it was believed to be a harsh approach that punished unwanted behaviors. More recently, the proponents of the neurodiversity movement called the intervention an affront to individuals with autism as according to them it attempts to normalise a child with autism rather than accepting him or her as naturally different. Nevertheless, ABA, which is now available in modified versions such as the Pivotal Response Training (PRT), is the most scientifically researched of all autism specific interventions and continues to be a treatment of choice for many.

TEACCH

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) was developed in the 1970s to target specific social, communication and developmental needs of the child. TEACCH is a highly structured approach that is conducted in an environment modified to accommodate the child.

RDI

Relationship Development Intervention (RDI) focuses on the parent- child relationship by training the parents through intensive workshops and videos. The goal of the therapy is the social development of the child with autism.

DIR Floortime

Dr. Stanely Greenspan (2002), a psychiatrist, pioneered the Developmental, Individual-Difference, Relationship Based (DIR) Floortime approach, which, as its name suggests, encourages the caregiver or therapist to get on the floor and interact with the child in an unstructured, playful manner. The goal of the intervention is to build an attachment with the therapist or caregiver by increasing the circles of communication with the child through following the lead of the child.

OT, Speech and Language Therapy (Splt) and Others

Apart from the autism specific interventions described above, most children require some degree of occupational therapy (OT) for psychomotor challenges and sensory integration and speech and language therapy to address language and communication issues. Recently, nutritional interventions that may include a diet of essential fatty acids, a healthy gluten-free, casein-free, soy-free (HGCSF) diet and vitamin/mineral supplements, have gained traction due to evidence of nutritional deficiencies, metabolic and digestive imbalances in children with autism (Adams et al., 2018).

I, too, opted for the most popular interventions for ASD for Moeez soon after he was diagnosed. For the first few years, Moeez’s regimen consisted of OT, TEACCH, and Splt apart from the playschool he attended. Lured by the promise of progress, I delved into alternative treatments like cranio-sacral therapy and homeopathy, switching from TEACCH to ABA when Moeez turned 8 years old. After Moeez entered double digits, he was weaned off ABA but continued with OT and intermittent Splt with decreasing frequency. In his teens, he received counseling as and when the need arose. While Moeez was growing up, art therapy was a very new and almost unknown profession in Singapore; hence, he was not able to avail its benefits. Moreover, my primary focus had been managing Moeez’s behaviors and teaching him life skills, like most other caregivers.

Challenges for Caregivers

Research shows that caregivers of children with autism experience higher levels of stress, anxiety and depression than those of typically developing children as well as children with disabilities other than autism (Fernell, Eriksson, & Gilberg, 2013; Teague, Newman, Tonge, & Gray, 2018). The stress emanates from challenging behaviors that are found to be more prevalent in children on the spectrum than in children with other intellectual and developmental differences. The behaviors may include acute tantrums, acts of aggression or self-harm toward self or others and socially unacceptable behaviors (Ang & Loh, 2019) as well as “children's disturbed sleep, agitation and cries, stereotypy and self-injury, difficulties in feeding and toilet training, epileptic seizures, lack of social or emotional reciprocity and other unusual behaviours” (Cappe, Wolff, Bobet, & Adrien, 2011). The severity of symptoms/behaviors in the children and degree of functional independence are correlated to the frequency of mental health issues in caregivers. Lack of social and emotional support and criticism from the community about certain behaviors may add to the anxiety of caregivers who are already dealing with multiple pressures at home. Benson and Karlof (2008) cite stress proliferation as another factor that may contribute to the stress of caregivers. Stress proliferation refers to primary and secondary stressors that act on each other to create additional stress resulting in psychological distress. For instance, sustained caregiving of a child with severe ASD (primary stressor) may translate into financial stress (secondary stressor) and so on. Referring to a study conducted by Benson (2006), the authors posit that stress proliferation is a strong predictor of self-reported depression in caregivers correlated to the severity of symptoms of autism. “The challenges in identifying, accessing, and paying for ASD services, given the nature of these children’s needs, available resources, and complex financing arrangements, can place a substantial burden on caregivers” (Cohrs & Leslie, 2017, p. 1416).

I recall several occasions with Moeez, especially when he was nonverbal, where a tantrum would emerge out of nowhere in the middle of a shopping mall triggered by some demand that he was unable to communicate. Although I was never an apologetic or embarrassed parent, these incidents were nevertheless stress inducing since they were unpredictable and difficult to manage. In Moeez’s younger days, visits to the barber for a haircut were often accompanied by behaviors such as involuntary laughter or singing that were a source of embarrassment to his younger brother who was learning to live with a differently abled older sibling. One particular incident still stands out in my memory as a traumatic event with respect to societal ignorance and lack of acceptance, when a woman openly threatened 12-year-old Moeez in a mall for accidentally backing his scooter on her ankle. She continued to rant at him even after she was told that he had auti...