Doing Therapy with Children and Adolescents with Asperger Syndrome

By Richard Bromfield

Praise for Doing Therapy with Children and Adolescents with Asperger Syndrome

"Providing an explanation of Asperger's based on a review of scientific research, Richard Bromfield describes how the characteristics of the syndrome affect the person's thoughts and experiences throughout childhood. Psychotherapy based on the practices described in this book will change the destiny of children and adults with Asperger Syndrome to one of greater connectivity to themselves and others. This should become the primary text for pshchotherapists working with children and adolescents with Asperger's."
—Tony Attwood, PhD, author of The Complete Guide to Asperger's Syndrome

"Dr. Blomfield generously shares his wisdom and experience in this very accessible, honest, and often moving book. Any clinician who reads it in its entirely—or even selects a chapter or two at random—will no doubt discover new paths to take their most complex and challenging clients and gain a greater appreciation for those with Asperger Syndrome. Bromfield gives us all a window into a world that is hard to describe, impossible to imagine, but needs and deserves to be understood."
—Naomi Angoff Chedd, LMHC, Autism Specialist and coauthor of Replays

Cutting-edge guidance for effective treatment of children and adolescents with Asperger Syndrome

Diagnoses of Asperger Syndrome in children and adolescents are on the rise, and while some clinicians have training and experience in this area, most do not. Using vivid case material, Doing Therapy with Children and Adolescent with Asperger Syndrome offers clinicians the guidance they need to treat the young people they endeavor to help.

• Language: English
• Publisher: Wiley
• Release date: Feb 25, 2010
• ISBN: 9780470609163

Richard Bromfield

Richard Bromfield, PhD, is a graduate of Bowdoin College and the University of North Carolina at Chapel Hill. A faculty member of Harvard Medical School, he writes about children, psychotherapy, and family life in both professional and popular periodicals. He is in private practice in Boston, Massachusetts.

Book preview

001

Table of Contents

Title Page

Copyright Page

Dedication

Preface

Acknowledgements

Important Notes

Chapter 1 - What Asperger’s Means for the Child

ASPERGER’S FROM THE CHILD’S EXPERIENCE

Chapter 2 - Meet the Parents

Chapter 3 - Beginning Therapy

Chapter 4 - Hypersensitivity

SENSORY OVERLOAD

THE IMPLICATIONS OF SENSORY SENSITIVITIES

STILL SENSES RUN DEEP

Chapter 5 - Anxiety

ASPERGER’S AND ANXIETY

HIDDEN FROM SIGHT

ADDRESSING ANXIETY

Chapter 6 - Communication

HELLO

SOME WORDS CAN SPEAK A THOUSAND WORDS

LITTLE PROFESSORS

SMALL TALK

YOU GOING TO EAT THAT PICKLE?

Chapter 7 - Intellect, Cognitive Style, and Creativity

ASPERGER’S AND IQ

COGNITIVE STYLE

NEED FOR SAMENESS

OBSESSIVE INTERESTS

HONESTY

SELF-ACCEPTANCE AND COPING WITH LIMITATIONS

PERFECTION

LEARNING DISABILITIES

CREATIVITY

Chapter 8 - Feelings and Depression

FEELING ONE’S FEELINGS

DEPRESSION

Chapter 9 - Social Difficulties

ASPERGER’S AND FRIENDSHIPS

THE THERAPY OF AN ELEMENTARY SCHOOL-AGE GIRL

THE THERAPY OF A TEENAGE BOY

THERAPY AND FRIENDSHIPS

BULLIES AND MEAN GIRLS

Chapter 10 - Theory of Mind and Other So-Called Impediments to Therapy

THE THERAPY

SO-CALLED IMPEDIMENTS TO THERAPY

Chapter 11 - Connecting It All

Appendix: Working with Parents

References

Author Index

Subject Index

About the Author

001

This book is printed on acid-free paper. 002

Copyright © 2010 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Published simultaneously in Canada.

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Library of Congress Cataloging-in-Publication Data:

Bromfield, Richard.

Doing therapy with children and adolescents with Asperger syndrome / by Richard Bromfield.

p. ; cm.

Includes bibliographical references and index.

eISBN : 978-0-470-60916-3

1. Asperger’s syndrome in children—Treatment. I. Title.

[DNLM: 1. Adolescent. 2. Child. 3. Asperger Syndrome—therapy. 4. Asperger Syndrome—psychology. 5. Autistic Disorder—therapy. 6. Psychotherapy—methods. WS 350.6 B868d 2010]

RJ506.A9B.92’858832—dc22

2009041457

For Lorraine, the best and sweetest aunt ever.

Preface

I clinically met my first children with Asperger’s and High-Functioning Autism in 1981 at Camp Wediko here in New England. Like many college students before us, my newlywed wife and I had driven north to New Hampshire to spend an intensive summer learning more about the careers we were about to enter: she, special education, and myself, clinical psychology. She was assigned to Think City, the camp school, and I was a counselor for the Stallions, a group of teens who, I was told, didn’t fit in with any of the other cabins or groups of children. I think you’ll find them interesting, the late and wonderful camp director said to me with a smile.

Within minutes of entering the cabin, I saw children who differed in ways immediate to my amateur eyes and ears. Unlike the other children I’d seen at Wediko and before, the Stallions didn’t interact with one another. There was none of the chitchat, jostling, and testing of each other that one expects from teens thrown into a mix. Some of the boys were withdrawn and barely able to say their names. Some boys talked loud and nonstop, not noticing when other people spoke or weren’t listening. A majority of the boys came from disadvantaged and stressed homes.

The rail-thin Dmitri recited the facts of his family’s ancestry; he couldn’t tell us the details of his own family. The stocky and smiling Eddie laced and relaced his sneakers as if his feet required 58 psi of pressure. Don, a lineman-sized teen from Boston’s inner city, giggled in a soft and high voice. Distracted and mesmerized by his dancing fingers, the delicate-looking Hardy paid little attention to the rest of us. Harlem’s wiry Carlos occupied himself as athletic boys are prone to do, balancing on one leg while tossing a baseball in one hand. These boys, and the rest of the Stallions, came in every size and color. Although at first glance they looked like 10 kinds of boys with 10 distinct issues, there was one thing they shared: a collective unease that was palpable. Never had I seen and felt a group of children so uncomfortable with themselves.

I had no idea how a real psychologist would have assessed and treated these boys. By the end of the summer, there was much my novice mind felt certain about. The boys were complex. And just as the camp’s director promised, they were intriguing.

In major ways, these boys seemed unlike most of the campers at Wediko that summer. They had greater difficulty communicating. It felt as if we had a cabin of 10 boys from 10 planets who spoke 10 languages. I often found myself translating one boy’s words into forms that the other boys or I could grasp. Oft times, we found that what on the surface appeared to be random words or behaviors actually spoke to the child’s fear or anxiety.

Communicating in social and group settings was especially hard for these boys. They didn’t sense the natural rhythms and beats, the give and take of conversation that the other children did. When our boys spoke out in wider camp settings, they were treated with rolling eyes, laughter, and teasing that could turn cruel. The average teen, no less the troubled ones at our camp, weren’t interested in endless punning or a lecture on geology. All but one of the Stallions were uncoordinated and inept at sports, depriving them of any street cred that might have raised their social stature in the camp culture. I and my fellow counselors spent a good deal of our focus and efforts protecting these boys from the rejection and humiliation ever ready at the hands of other campers who had their own issues of esteem.

But as unique and out of the ordinary as these boys were, it was the sameness of their humanity that had then struck me. Dmitri’s interest in rocks may have sounded excessive and compulsive to the rest of us, yet he wanted his interest shared and respected, as might any other boy telling a more measured and engaging story about his new dog or his exploits on the baseball field. However odd and preoccupying Eddie’s perpetual readjusting of his laces and clothes looked, he dearly appreciated my noting just how impossible it was for him to get comfortable. Hardy liked that I gently helped him to focus when we spoke and that I didn’t stare at his wiggling fingers or critique his fascination with his hands. One didn’t have to be a psychologist or autism expert to notice that for all their awkwardness, these boys wanted friends, just as they sought—and could profoundly feel—kindness, generosity, acceptance, respect, affection, and, perhaps more than anything, understanding for who they were, warts and all.

Even then, I grasped that being the Stallions’ counselor from dawn to late night, though arduous, was nothing compared to what those boys faced, surviving away from their families and neighborhoods in a strange wilderness of nature and peer culture. Even at this early stage of our professional careers, it was obvious to every counselor in our cabin that these boys—The Mighty, Mighty Stallions—faced developmental challenges far greater than did the typical children we knew outside of camp. Having Asperger’s or High-Functioning Autism wasn’t a pass that exempted these boys from any part of life and development. Our boys had the same psychological needs as did every nonautistic boy. Our boys had to grow life skills, competencies, esteems, identities, and so on, just as other children did. Their developmental difficulties and deficits—the ones I would soon learn had to do with autism—only made those psychological tasks harder to face and manage. As if not enough, the Stallions had additional problems. Dmitri had asthma and a neuromuscular disorder, Hardy had gender confusion, Eddie had learning problems, Don had been neglected, and Carlos had been abused. Even then, a veritable toddler in the world of mental health, I could see the disproportion and unfairness in the boys’ developmental burdens.

A few weeks after leaving Wediko, I enrolled in a doctoral program in clinical psychology at the University of North Carolina. There, I soon learned officially what autism was about. The university was the home of Dr. Eric Schopler and TEACCH (Treatment and Education of Autistic and related Communication-handicapped Children), his innovative and maverick program for children with autism—a program that would come to be internationally recognized. When I told Dr. Schopler about Wediko and the Stallions, he smiled. He made clear his strong opinion that my enthusiasm was a product of a naive generosity of spirit, a phenomenon he’d said he witnessed in many beginning psychologists.

Dr. Schopler proceeded to straighten my thinking. He explained that I had projected my feelings onto my campers as if they (my words, now) were walking Rorschach inkblots. I had seen—imagined, Dr. Schopler would have corrected—in those boys what I’d wanted and needed to perceive. According to Dr. Schopler, my attributing feelings and thinking to those boys was as inaccurate and unfounded as believing my dog was distressed by the nightly news, or better yet, happy over the town’s expanding its off-the-leash park hours.

Dr. Schopler’s input was neither critical nor unkind. His motive was compassionate and well founded for the children with autism that he’d long studied and knew so well. His point was that by assuming these children had inner experiences that (he believed) they did not, my misplaced sympathy was burdening the children with irrelevant understanding, missing out on who they really were and what they really needed. To see them as I would see any other children implied that I would treat them as such, and Dr. Schopler knew from harsh reality that this would mean these children would go without the interventions that truly offered them help. In short, and by his view, my sensitive view of these children was paradoxically cruel and unresponsive to a population of children that already suffered too much.

As a young psychologist starting out, I was in a quandary, torn between the wisdom and insights of the world’s expert and the reality I had observed in the presence of those boys. Perhaps, I wondered, he was right. Had my wish to connect with these children and my wish for them to connect with me blinded this therapist to the truth? Was I viewing the world of Asperger’s and High-Functioning Autism through distorted or discolored glasses? I knew how Dr. Schopler would have answered those questions; I wasn’t so sure myself. That my perceptions of these children might actually be born out of sentiment unnerved me. The last thing I wanted was to harm children and their families. And more so, if I could be so mistaken and misguided when it came to autism, what did that say about my general abilities and fitness to be a psychologist?

I didn’t actually treat a child with autism until my fourth year of graduate school. I was an intern at the Massachusetts Mental Health Center, a training hospital that partnered between Harvard Medical School and the Commonwealth of Massachusetts to serve the Mission Hill area of Boston. I was assigned to Timothy, a 6-year-old boy recently discharged from the inpatient unit to the outpatient clinic. Over several years, Timothy had been diagnosed with Infantile Autism by several prominent child psychiatrists and clinics in Boston, including the developmental team at the famed Children’s Hospital Medical Center. Timothy had been an unresponsive infant and toddler, showing all of the defining traits for Infantile Autism according to the Diagnostic and Statistical Manual of Mental Disorders III (DSM III; American Psychiatric Association [APA], 1980).

When I met Timothy, I met a boy who neatly fit the formal diagnostic criteria. He spun, made no eye contact, sniffed everything, reversed his pronouns, repeated most every phrase to a fading echo, was obsessed with television shows and trivia, and noticed when so much as a paper clip moved from my desk. His intellectual skills and development were initially tested at the borderline to low-average level. But what else did I find when I met and got to know this child?

I found a boy who hungered for a connection with me, his new therapist; a boy who, for all of his inability to show affection, painfully missed his previous therapist; a boy who wanted me to recognize his vulnerabilities and fears, especially those involving his being in therapy and with me. I found a boy who wanted me to respect his interpersonal anxieties and move at a pace he could tolerate—physically, emotionally, and psychologically—neither too close nor too far away; a boy who wanted me to accept him as he was and not to demand eye contact, affection, or any other conventional sign that I mattered to him; a boy who worked hard and tirelessly to get me to grasp what he tried to communicate and who let me know loud and clear when I got it and when I didn’t. Despite his IQ testing, I found a boy who enjoyed playing with language, and in spite of what the literature said about autism and stunted play, I found a boy who immensely enjoyed his own kind of play. Most profoundly, I found a boy who ever sought my understanding and who, I soon learned, ever did his own version of beaming when it came, when I was able to deliver it. Even when I read and reread all that autism literature had discovered and pronounced, even when I questioned my own clinical vision, I couldn’t dismiss the pervasive and obvious signs that Timothy shared the big human needs that I, my wife, and every other person I knew lived and breathed. And in case I haven’t made it clear enough, as you will read in Chapter 10, I found a boy who could talk and play in psychotherapy and who could profit from a long-term therapeutic relationship.

Prior to my meeting Timothy, leading professionals in Boston had told his parents that he would never live independently, would never make it through school, would never ride a bicycle, would require residential schools as a child and a sheltered workplace as an adult, and so on. To make a long story short, Timothy not only made it through high school, but he also graduated from one of the country’s leading engineering universities. With each successive testing, his intellectual functioning rose until leveling in the high-average to superior range. Timothy learned to ride a 10-speed bicycle very well and as a teenager used it to commute all over the city, from his home to Fenway Park (where he worked as a food vendor), to the Boston Public Library (where he read newspapers from around the world), to the YMCA (where he competed in a recreational league), and so forth. He also learned to drive a car and fly a plane. In his late twenties, Timothy now lives on his own in a home that he supports with a highly skilled professional job. Timothy has good friends and is an active member of his church community, an avid sports fan and weekend athlete, and a news junkie.

Over much time, my experience with such children has only grown, deepened, and richened. Time and time again, I’ve seen these children engage and play and talk in ways never thought possible. I’ve listened to them describe thinking, feeling, and imagining that has been said to be beyond the powers of their brains. I’ve watched these boys and girls smash through glass ceilings and keep growing toward the sky, surpassing by miles the low expectations that professionals once predicted. Thank goodness these children and their parents hadn’t taken those prophesies of gloom to heart and downgraded their hopes and aspirations. Admittedly, as I’ll detail, these wondrous possibilities didn’t come fast, and the work challenged me as much as it did the children and their families.

For decades, children with Asperger’s were pronounced to be incapable of certain kinds of experiences. Therapy that involved play and talk was equated with psychoanalysis and judged to be not just unhelpful but destructive. Therapy that talked of inner experience and relationship building was dismissed as quackery tantamount to treating autism with chelation or a testosterone-suppressing drug. And yet, every child I have seen with Asperger’s or High-Functioning Autism has taught me that more than anything, they need that connection to others—and more so, to themselves—and that they have all they need to teach us, their therapists, the best ways to reach, engage, and sustain them.

We have come light-years from when autism was said to be an acquired disorder of otherwise normal children caused by cold and unresponsive mothering (Bettelheim, 1967). By 1981, the year I entered graduate school, it was well-established scientific fact that Asperger’s and High-Functioning Autism are neurological syndromes involving brain-based deficits in the processing of language, emotion, and social experience. Unfortunately, this enlightenment brought along blind spots and biases of its own. The pendulum was necessarily pushed from its errant and malignant position to its opposite, neurologically accurate side. There, it got stuck.

Consider the authoritative Journal of Autism and Developmental Disorders . I felt disappointed when, about 20 years ago, it rejected my article on doing play psychotherapy with a child with Asperger’s. As of June 2009, in its 39 years and 2,262 articles published, that journal—devoted to all aspects of autism spectrum disorders [including] clinical care, education, and treatment for all individuals—had not published one single article on psychotherapy or counseling for children with Asperger’s. A handful of articles made cursory mention that supportive counseling might help but gave no details as to what that counseling would be. There has been a bias in which it seems the whole child got misplaced.

My intent is not to point the finger. Both the therapeutic approach I propose in this book and the children I treat have benefited from my reading that journal and others like it. On the contrary, we all—people with autism, their families, and clinicians alike—owe a great debt to those who righted Bettelheim’s misconception, arguably one of the most destructive blunders of modern psychology and psychiatry. The heroic deeds of these autism researchers reversed an entire field, and any bias against approaches like mine came out of a need to guard against echoes of a dark past that should never be repeated. Their vigilance, neither error nor misstep, was understandable as steadfast protection of what research had shown them and to prevent even one more mother from being blamed and one more child from being diverted from the most efficacious education and treatments.

Times have been changing, and so has the world of autism and Asperger’s. Knowledgeable and wise clinicians such as Asperger’s greatest friend and ally, Tony Attwood, are leading and helping us to grasp the realities and experiences of the whole child so that we can best understand and help. Clinical interventions, such as Levine and Chedd’s replays (2007) and Greenspan and Wieder’s floortime (2006), address and employ the relevance of affect, empathy, and connection, enabling clinicians to respond to the child in deeper and more complete ways. Basic research, too, as you will read all about, is finding out new things that suggest there is more to and in children with Asperger’s than has been believed.

It is an exciting and opportune time to be working with children who have Asperger’s or another spectrum disorder. The research of brain science, neurology, psychiatry, and developmental psychology are propelling our understanding and the futures of children beyond what we imagined. Diagnosis is sharpening and awareness is rising such that parents, educators, and clinical professionals are identifying these children earlier, permitting the early interventions that are key. Educators are designing programs that better address these children, and school systems are seeing the value of building those methods into their special education curricula. Psychiatry is leading the way in discerning the basics of Asperger’s Syndrome, teasing out its complex relationship to comorbid disorders and learning which drugs target children’s symptoms more sensitively and with fewer side effects. Rather than being rebuked and rejected as the problem, loving mothers and fathers are being given the support they need and deserve so as to learn all they can to effectively parent and advocate for their children. At the end of the day, greater awareness, more sensitive detection, and an actual rise in incidence will guarantee that more clinicians will see growing numbers of children with Asperger’s (Hertz-Picciotto & Delwiche, 2009).

Though what these children have taught me seems to be hugely relevant and important, please be clear that my approach and vision in no way makes obsolete or replaces all or any of what we’ve learned about Asperger’s and High-Functioning Autism as neurodevelopmental disorders. The approach to therapy that I’ll lay out in detail does not supplant behavior therapies, language therapies, or social pragmatics, to name a few. It is a relationship-based therapy that informs, augments, and enriches all of the other therapies (just as those strategies inform, augment, and enrich what I do). I think of my approach as an atmosphere and view that hovers above and stands alongside other interventions. When facing a challenge such as Asperger’s or High-Functioning Autism, children and their families need all there is to offer—the best of all worlds. And the sort of therapy I propose, so my patients have shown me, has a place in that universe of possibility. Whether clinicians embrace my vision or simply add pieces of it to their therapeutic armamentaria, repertoires, or toolboxes is up to them.

A discussion of what Asperger’s means, not just diagnostically but to the child, starts off the book. What is the child’s subjective experience? The second and third chapters explore the beginning hours of therapy for parents and children, respectively. For the remainder of the book, chapters focus on prominent aspects of the Asperger experience, including: hypersensitivity, anxiety, communication, intellect and