OBSESSIVE- COMPULSIVE / BIPOLAR DISORDER
In a boy with AUTISM
Reported by James MacDonald and Jodi ( John’s mother)
John (W) was four years old. While he had a vocabulary of over 300 words, he mainly talked to himself in rote phrases, rarely communicating with his language. His parents saw him as intelligent since he read at the first grade level, solved many problems creatively, and mastered computer games. They were concerned that he spent his time mainly in isolated and obsessive activities, resisting intrusions violently. When he began an activity he was insistent about continuing it and seemed to get lost in it with little concern with finishing it. John was a boy with substantial cognitive skills and considerable language but very little social communication or motivation to interact with people. He had limited social-emotional skills such as self-regulation and empathy.
As his second year in the program progressed he showed more language, but it was not communicative. He appeared to have his own language, which his family did not understand. Unless he was in control of the situation he showed considerable anxiety, which prevented interaction with others. He received several diagnoses- OCD, bipolar disorder, Attention deficit disorder, Emotional disturbance, Oppositional behavior, mild retardation, schizophrenia, and mild autism. His parents were at their wits end, confused with so many concerns and conflicting recommendations. Videotapes of John between six and 12 months old revealed that he had been interactive, playful and beginning to talk. By age two he was resisting other’s contacts vigorously, insisting on playing.
During the first month, we observed John in the clinic and home for several hours, to assess his cognitive, motivational, communicative and social emotional development since each varied across situations markedly. We identified the situations in which he would interact, and then recreated them to begin the program. The first goal was to help John interact back and forth in ways not totally on his terms. We discussed with the family how to enter his world without threatening him and to read his emotional state to identify when he was open to social contacts. John’s mother recalls an important early breakthrough when she began visualizing John and herself on a development staircase and that the closer she was to his step the more he would learn. She came to realize that she was often acting as if she was on the tenth step and John was on the second step of the staircase. She admitted that she wanted him to have adult conversations, socialize typically, and enjoy others, and come to realize that her expectations were far above what he was ready to do. The program began by teaching Jodi to play in John’s world and to accept anything safe that he did. His first pivotal goal was to tolerate Joint activities with others. We explained that regardless of how much language and knowledge John had by himself, he would fully develop to the degree that he interacted with others. We discussed several topics over two months to understand how critical social interaction is to developing cognition and communication. We practiced several strategies such as balancing to build a reciprocal habit making the interactions stress-free and enjoyable) and matching their behavior to John’s interests and abilities Joining into John’s play took considerable patience on the family’s part. They began by playing parallel to his play without intruding on his activity. He resisted at first but began to enjoy and attend to them when they imitated him with no demands. Jodi realized that she had believed she needed to teach him the “right” way of doing and saying things, which resulted in rage and resistance. Now she saw that when she simply joined in his play side-by-side, he began attending to her more and even imitating the ways she was playing at times. He now occasionally smiled and began showing her things he was doing, which was a first. She was learning to fine-tune herself to his interests, his emotional state and to his current abilities. The more she acted like John, the more he attended to her and invited her into his activities. It appeared that he was more open to her once he was convinced that she was not going to dominate his play with directions to do things that did not interest him or that he might fail. Learning to be safe in social interactions was a first major phase of the program. The family was pleased when he began enjoying their company more, if even only occasionally, and when he began coming to them more to interact and to act and talk in ways they were doing.
In general Jodi was becoming a very responsive partner to John, and she found that when she did less in an interaction with him he did more. It was clear that there was some real basis for an emotional attachment between them when she accepted what he did and responded in ways that helped him succeed. John’s mother no longer worried about whether he was talking or playing in the ways she thought were” appropriate”. Her concern now was for him to accept her into his activities and experience success interacting with others.
The next phase of the program was to develop the pivotal goal of Intentional communication. The family was very concerned that John rarely talked to others. While he did have some language, little was understandable or used with others. When the family focussed on helping him make sounds clearer, he was frustrated and avoided them. We discussed how any behavior can communicate and demonstrated that responding to any of his behaviors without correction would help him communicate more . The family found that when they responded to all of John’s sounds and words without judging them, he began talking more to them and less to himself. His self-talk and insistence on his own topics still predominated, but his mother was enthusiastic that he was beginning to “talk to me at last”.
John interacted more when they had a schedule of predictable routines on a one to one basis. Previously, most of his time had been in groups with considerable distraction. We discovered that John found many kinds of stimulation aversive and he retreated. The home program then focussed on five daily routines that he would allow his parents into and that resulted in little agitation. Avoiding agitating situations became a major issue since once John became anxious, he violently resisted social contact for up to several hours. Jodi was learning when John was ready to learn and when he was not. The daily routines were a computer game, photograph books of the family, car rides, bath-time and quiet bedtime.
In the daily routines, Jodi acted and communicated in ways John did and then occasionally translated his unclear speech into single words that were appropriate to the situation. Gradually, John began to respond more to her and to direct his words to her occasionally. The progress was slow but it was occurring. We needed to reassure the family that John’s habits of not interacting were longstanding and that he would learn that interacting was safe and rewarding only slowly. John’s family learned to ignore his undesirable behavior and focus on responding to the appropriate social contacts and language that were increasing. Jodi learned that, while her prior interactions had been mainly verbal, now she found that when she reduced her talk greatly John began talking more. We also noted that his speech became clearer when he directed it more to others than to himself and when we reduced our language to his level.