Autistic children

Silvia Tendlarz is a member of the Escuela de la orientación lacaniana and the École de la Cause freudienne

The twenty-first century has been witnessing an increasing frequency in the diagnosis of autism in childhood. It has even been spoken of in terms of a true epidemic. Does the diagnostic expansion always correspond to the individuals involved in it? One pressing question is the following: this is just not about diagnosis but about what constitutes a viable treatment proposal for autistic children.

Autism has the particularity of starting in early childhood. There are also autistic teenagers and adults who, despite variations in most cases in the presentation they had in childhood (due mainly to the expansion of language use), maintain some unmodified characteristics without this forecasting a tragic destiny that one would have to accept with resignation.

First of all, it is necessary to distinguish autism from the concept of “autistic jouissance”. Autism is not a disease of the broken bond, some kind of expression of our modern world, even though there is a current prevalence in our language of saying that we are “all autists”. Jouissance is always autoerotic, autistic, regardless of the type of bond that prevails in our contemporaneity. The term “generalized autism” names jouissance, it supposes the bond with the other, without this generalization implying a diagnosis. Moreover, Jacques-Alain Miller indicates that autism in its broad sense is a transclinical category: it is the native state of the subject to which the social bond is added.

A brief outline of the story of the notion of autism will allow us to examine the psychoanalytic approach, in its conceptual and clinical aspects.

Diagnosis

Infantile autism has its story. In 1943 Leo Kanner introduced the concept of “early infantile autism”. A few months later, in 1944, and in another context, Asperger started his developments on so-called “Asperger’s syndrome”. The first remains an interface between psychiatry and the psychoanalysis. The second follows an educative course, since from the beginning Asperger was proposing a curative pedagogy.

The concept of autism itself is particular. It is the great survivor of the diagnostic collapse propose by the DSM-IV. Both Kanner’s “Early Infantile Autism” and “Asperger’s Syndrome” are part of the “Pervasive Development Disorders” (PDD), which emphasize developmental disturbance.

Kanner’s description of autistic children indicates that they present difficulties: in their relationship with the other (rejection of the gaze, absence of spontaneous behavior like pointing at objects of interest, or lack of social and emotional reciprocity); in communication (delay or absence of oral language, stereotyped use of language or incapacity to establish conversations); and in behavior (lack of flexibility, rituals, absence of symbolic play). He names its essential characteristics “aloneness” and “sameness”[1]. The adjective “early” indicates that is manifests itself from birth or in any case before the child’s third year. This early start determines its presentation modality.

It is distinguished from Asperger’s Syndrome by the fact that the latter lacks the delay in language aquisition and is recognized or begins later. In his diagnosis, Asperger indicates traits that are life-long, the syndrome is not developmental and changes in the diagnosis do not occur.

In the Diagnostic and Statistical Manuals they are both distinguished from childhood schizophrenia on the basis of the absence of hallucinations, although as Lacan says, autistic children also have hallucinations, whose particularity most be examined.[2]

DSM-V, soon to be published, eliminates this distinction and introduces a new clinical category: “Autistic Spectrum Disorders” (ASD), with its grades: low, moderate and severe. The criteria used for this diagnosis are social and communicational deficits; along with fixed interests and repetitive behavior. Thus, autism is becoming a broadened diagnosis that includes distinct types.

The question as to whether children diagnosed with early infantile autism are able to evolve into Asperger’s syndrome in adulthood will eventually disappear in this context since they will both fall under ASD. However, the clinical subtlety of this question remains, in so far as one can observe a change from childhood to adulthood which shows that not all autistic children necessarily remain with their initial presentation throughout their lives, nor do their so-called “cognitive disorders”, assessed in childhood, persist. The names of the classes, as Ian Hacking says, interact with the individuals involved in them, but are nevertheless insufficient when it comes to accommodating the subjects and their differences.[3] Beyond the fate of the diagnosis, there still remains that which makes each subject unique and impossible to dilute into the “norm”.

Cognitive theories have introduced the notion of “autistic spectrum” which includes both children and adults. A 1979 study by Wing and Gould forms the basis of this concept. [4] They argue that all children presenting a severe social handicap also shared the core symptoms of autism. In their view, children who are affected by similar difficulties in social reciprocity and communication, and who have restricted behavior, require the same cognitive treatments as people with autism. They all fall within the autistic spectrum, thus greatly increasing the incidence of autism.

This notion is linked to the diagnosis of “Pervasive Developmental Disorder not Otherwise Specified” which, due to its lack of defined criteria, includes more cases of autistic spectrum than of autism. This is one of the points of discussion within the proposed DSM-V.

Moreover, insofar as there is no specific medication for autism, children are medicated for anxiety, depression or hyperactivity. The postulate of organicity and the disturbance of the executive function in cognitive theory on which ADD and PDD are based, together with the purely descriptive approach, blurs the boundaries between these clinical pictures.

As matter of fact, “deficit” was never a good diagnostic criterion as it led inevitably to the use of medication and behavioral therapies to alleviate it. Every last child becomes “educable and medicable” in the name of curing the symptom without taking into account the cause and the singular treatment it calls upon. In the name of “normality”, what is sough is to re-educate children to make them like the others. What is thus ignored is the fact that there exists no norm that is valid for everyone alike, and there is no universal criterion of health. Everyone is different, everyone is “normally” outside the norm at the point where singularity is addressed. Autistic children have their own way of “functioning” within their structure.

From a perspective outside of psychoanalysis, the neurologist Oliver Sacks, in his book An Anthropologist on Mars, states that no two autistic individuals are alike: “its precise form or expression is different in every case”.[5] We may add that any two individuals are unlike, autistic or otherwise.

Autism Epidemic

The diagnosis of autism in children has been multiplying in recent times. This increase has implications for both treatment and Public Health policies. However, is there really an increase in the number of autistic children or does this correspond to the way the categories of classification in use in the world today are being read?

With the emergence of this larger number of “autistic children”, a rumor broke out that shook in the public. In 1998 The Lacet published a study by Dr Wakfield from North London’s Royal Free Hospital in which he set out a hypothesis of the relationship between the rubella vaccine and autism. The media contributed to create a major scandal which spread via the Internet.

In connection with this scandal, François Ansermet has recalled[6] how a 2004 study revealed that a team of lawyers had paid Dr Wakerfield to publish the news, and immediately began proceedings against the producers of the vaccines. In March 2004, The Lancet published a short editorial in which they recanted[7], but the rumor continued to circulate.

The grain of truth behind this rumor is that to think of autism as a deficit linked to genetics, to think that it is constitutional of even secondary effect of a vaccine, generally relieves parents as it distances them from their painful feelings.

The search of a defective gene has reached such a point that, face with the trouble they are having in finding an “autistic gene”, scientist have begun to speak about “spontaneous genetic mutations” linked to the environment. The decoding of the human genome has introduced the belief that ultimately it will be possible to establish the genetic sequence that will allow autism to be isolated. In June 2010, The Genome Project Consortium published an article in the journal Nature where they reported finding duplications and loss of fragments of DNA in 20% of autism cases examined. They speak of “rare variations”, unique mutations that have nothing to do with heredity, but are each different. The cause of these genetic changes has not been established, so the “environmental cause” remains a legitimate perspective. The genetic argument such as it has been set out leaves re-education as the only viable alternative. It remains to be seen whether this “environment” will include or not the subject’s relation to the signifier.

The discrediting of psychoanalysis is correlative to the increasing use of cognitive-behavioural treatments for autistic children, which help spread the belief that psychoanalysis blame parents for their children’s condition. Ian Hacking, in The Social Construction of What?, considers this perspective and mentions how cognitive science currently “rules somes roosts”[8] by explaining autism through the “theory of mind”, given the linguistic and the other deficits that are met in “autistic children”. This theory refers to the ability to attribute mental states to oneself and others, effectively amounting to an imaginary version of the Other.

Autism is not a calamity, says Jacqueline Berger, journalist, author of the book Sortir de l’autisme,[9] and mother of two autistic children. The bad reputation of psychoanalysis corresponds to the fact that the results it obtains are not measurable according to the quantitative and statistic criteria used by cognitive behaviorist in scientific publications.

On the Side of Psychoanalysis

Jean-Claude Maleval looks at the diversity of cases involved in the diagnosis of autism, ranging from cases requiring institutional care for life, to cases of high-functioning autists. Some children have “islets of ability” which often make them “savants” in highly specialized domains, even with exceptional skills.[10] Sacks examines the characteristics through which they become “prodigies” whose technical prowesses, says Éric Laurent, have shifted the focus of interest that used to be placed on delusion.

But autism cannot be grasped by the sum of it symptoms given that it is not a disease but a singular subjective functioning. In so far as it constitutes a particular clinic type, there is no “normal” child lurking hidden behind his shell. The conception of autism as a deficiency that places them in the category of disabled children inevitable limits them to exclusively educational treatments and turns away from the subject’s participation in a functioning that does not seal his or her destiny.

Maleval posits that autism is a structure characterized by a rejection of signifying alienation and by a jouissance that returns to a rim. This expression, borrowed from Éric Laurent[11], accounts for the way in which the object remains stuck to the body in such a way that it constitutes an “autistic shell” in its particular libidinal dynamics.[12] The symbolic disorder generates a dead enunciation that is either displaced, erased or purely technical. It is not a cognitive deficit but a particular relationship to the signifier. This rejection prevents jouissance from embarking on speech, and it returns instead on a rim, together with an object to which the autistic child is stuck: a shell is thus built within a libidinal dynamic. The autistic border is a protective formation faced with a threatening Other, and it has three essential components: the image of the double, the islets of ability and the autistic object.[13]

Maleval’s central hypothesis is that the autist’s rejection on the jouissance associated with the object voice determines the language disorders. What is at stake here is not sonority but rather the enunciation of his act of saying. “Nothing is more anxiety provoking for the autistic child”, says Maleval, “than to cede his vocal jouissance, alienating himself in the signifier”. He then protects himself from the anguishing presence of the voice through verbosity or mutism, and he avoids the Other’s interlocution. Even when they speak fluently, as in the case of high-functioning autists, they protect themselves against vocal jouissance through the lack of enunciation. This is where the loneliness of the autist stems from, when it comes to taking up a position of enunciation, as well as the fixity in his effort to maintain a static order against the chaos in his world.

Maleval the posits two possible types of way out which range from the creation of a double in childhood, to the creation on an Other of synthesis in adulthood through the memorization of sings and, finally, the use of highly complex autistic objects. Thus, from the loneliness and mutism of early autism, it is possible to find the Asperger’s syndrome of adulthood in a second phase, after having worked on the jouissance that returns on the rim.

These developments are lines of research that enable us to reflect upon their functioning within the analytic setting.

Éric Laurent shows that the inclusion of the subject in autism implies the functioning of a signifier that stands alone in the real, without any possibility of displacement, a “spare part” acting in such way as to seek a fixed order and a symbolic that is realized without any possible equivocation, a true “cipher of autism”.[14] Not being able to empathize is not necessary a deficit, rather it allows such children to function without the imaginary obstacles of everyday life. On the other hand, Laurent adds, “we must give up the idea of the “mechanical child”” –alluding to the Joey case by Bettelheim– and “speak rather of the ‘organ child'” since what is a stake is “the montage of the body plus an object outside of the body”.[15]

As for the particularities of the treatment, Éric Laurent shows that autistic encapsulation is a closed “protective bubble”[16] of a subject without a body. The problem is therefore not so much how to build a rim, as in schizophrenia, but how to displace this neo-rim which is in itself very well constituted.

When the autistic child is brought to a consultation, he often reject any contact with the other in so far as it is experienced as intrusive faced with an encapsulated rim that is almost stuck to the surface of his body. Through exchanges articulated with an another who is experienced as less threatening, the shell is displaced. What is sough is the building of a space that is neither the subject’s nor the other’s, a space that allows for an approach that extracts the child from his indifference and his exact repetition of the relation with the other, and thus articulates a “space for play” –although it remains to be specified what the status of this play is. These exchanges in the real (which are not therefore purely imaginary), in which the metonymy of objects intervenes, allow for the construction of a space for the displacement of the rim and the emergence of signifiers that become part of the child’s private language.

At times the “autistic object” with which the child circulates is included and it also enters the circuits of objects. This object is part of his personal invention, so while the analytic orientation aims at the operation of “separation” –without however inscribing it– this by no means implies that the child has to be deprived of this object.

In so far as the treatment target singularities, it is possible to be attentive to the manifestations of the signifier that stands alone in the real, listening to the subject without objectifying him, and learning his language, to use Jean-Robert Rabanel’s expression. The autistic person’s “bondless” dimension, his rejection of the other experienced as intrusive, give an even greater importance to the interventions through which the analysis becomes the partner of the autistic child, so that his speech may be heard.

Éric Laurent states that in order to apply psychoanalysis to autism it is necessary to allow the subject to separate himself from the state of homeostatic retreat, his retreat into his encapsulated body, and move into a mode of subjectivity that partakes of an “autism for two” (à deux).[17] It requires us to become the new partner of the subject, outside any imaginary reciprocity and without the function of symbolic interlocution.

It can be affirmed that there is transference in the direction of the treatment of the autistic child: in each case its particularities and its consequences in the treatment have to be established. It calls upon invention not only on the side of the child, but also on the side of the analyst.

As for the interviews with the parents, it is not about deserting parents by making them feel guilty, but guiding them towards the different treatment options. The straightforward interview comprised of questions tends to cause a feeling of being at fault, even without any theory that points at the parents as a cause of autism. This is an essential element to bear in mind in consultations with children, if we do not want to leave the parents without resources, which can only lead them to turn to so-called “quick” re-education solutions.

To conclude

Psychoanalysis is a legitimate treatment alternative for the autistic persons, both in individual work, working with the setting created around him, and within the framework of institutional practice “among many”. Its treatment teaches us that the subject can never be reduced to an object of diagnosis, on the contrary, when approaching him, in the way analysis is able to, doors are opened to a singular universe that not diagnostic manual could ever anticipate.

For an autistic child, just as for any child with any other diagnosis, there is no other “normality” but that of his or her own mode of functioning.

To address the autistic child as a subject, and not as a educable object, introduces the possibility of an unexpected encounter with solutions that allow him to reinsert himself in the Other in an original way, without him being shut away in a handicap or in pre-established protocols. It is a one-by-one treatment, but with others.

Translated from the Spanish by Florencia Fernández Coria Shanahan
Originaly published in Departamento de Autismo y psicosis, May 2011

* Publicado en Hurly Burly, The International Lacanian Journal of Psychoanalysis, issue 7, mayo 2012

NOTES

1. Kanner, L., “Autistic Disturbances of Affective Contact” in Nervous Child, Issue 2, 1943, p. 249.
2. Lacan, J., “Geneva Lecture on the Symptom”, transl. by R. Grigg, in Analysis, Issue 1, 1989, p. 19.
3. CF. Hacking, I., “Madness: Biological or Constructed?” in The Social Construction of What?, Harvard University Press, Cambridge, Mass, 1999, pp. 100-125.
4. Wing, L., I., & Gould, J., “Severe Impair of Social Interaction and Associated Abnormalities in Children: Epidemiology and Classification” in Journal of Autism and Developmental Disorders, Issue 9, March 1979, pp. 11-29.
5. Sachs, O., An Anthropologist on Mars: Seven Paradoxical Tales, Knopf, New York, 1995, p. 250.
6. Ansermet, F., Siegrist, C.-A., “Vaccin rougeole et autism, aucune evidence scientifique”, Tribune de Genève, 6 May 2008, p. 33.
7. The Lancet, Vol. 363, No. 9411, March 2004, pp. 823-4.
8. Hacking., I., The Social Construction of What?, op. cit., p. 115
9. Berger, J., Sortir de l’autisme, Buchet, Paris, 2007.
10. Cf., Maleval, J-C., “Langue verbeuse, langue factuelle et phrases spontanées chez l’autiste”, in La Cause freudienne, Issue 78, 2011, pp. 77-92.
11. Laurent, É., “Lecture critique II” in L’autisme et la psychanalyse, PUM, Toulouse, 1992, p. 156.
12. Cf. “La conversation de Clermont: enjeux d’un débat”, in La Cause freudienne, Issue 78, op. cit., p. 113
13. Maleval, J-C., L’autiste et sa voix, Seuil, Paris, 2009, p. 108
14. Laurent, É, “Le chiffre de l’autisme”, in Le nouvel Âne, Issue 8, February 2008, p. 16.
15. Laurent, É., “Autisme et psychose: puorsuit d’un dialogue avec Robert et Rosine Lefort” in La Cause freudienne, Issue 66, 2007
16. Laurent, É., “Les espectres de l’autisme”, in La Cause freudienne, Issue 78, op. cit., p 56 (English translation planned for the next issue of the Psychoanalytical Notebooks of the London Society (Issue 25, 2012)
17. Laurent, É., “Autisme et psychose: poursuite d’un dialogue avec Robert et Rosine Lefort”, op. cit.