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Journal of Behavioral and Brain Science, 2017, 7, 545-556
http://www.scirp.org/journal/jbbs
ISSN Online: 2160-5874
ISSN Print: 2160-5866
DOI:
10.4236/jbbs.2017.712039 Nov. 22, 2017 545 Journal of Behavioral and Brain Science
The Theoretical Principles of the
Body-Centered Therapy to Promote
Affective Attunement in Children with
Autism Spectrum Disorder
Magda Di Renzo
Institute of Ortofonologia (IdO), Rome, Italy
Abstract
Background:
The roots of autism spectrum disorders become evident in first
attunement mechanisms between mother and child that allow a first level of
mentalizing. Neurosciences and current developmental theories confirm the
existence of defensive mechanisms related to body and affectivity that psy
-
chodynamic theories had already highlighted. Reading child’s behavio
r not
only by administering tests but also through careful clinical observations
allows a better understanding of the communication and social difficulties
present in autistic children. The identification of the zone of proximal
development can promote a therapeutic intervention that respects the indi
-
viduality of the child and the specificity of his relational approach to the
world.
Conclusion:
The paper presents the theoretical principles of a body
-
centered therapy
to promote the attunement processes necessary to activate
cognitive resources.
Keywords
Autism Spectrum Disorders, Body-Centered Therapy, Affective Attunement,
Mentalizing, Clinical Observation
1. Introduction
As it is well known, a number of changes were made to pervasive developmental
disorders (PDDs) in the recently released Diagnostic and Statistical Manual of
Mental Disorders, 5th edition [1]. The proposed DSM-5 criteria for autism spec-
trum disorders have been reduced so that the ASD symptoms are best represented
How to cite this paper:
Di Renzo, M.
(201
7)
The Theoretical Principles of the
Body
-Centered Therapy to Promote Affec-
tive Attunement in Children with Autism
Spectrum Disorder
.
Journal of Behavioral
and Brain Science
,
7
, 545-556.
https://doi.org/10.4236/jbbs.2017.712039
Received:
September 26, 2017
Accepted:
November 19, 2017
Published:
November 22, 2017
Copyright © 201
7 by author and
Scientific
Research Publishing Inc.
This work is
licensed under the Creative
Commons Attribution International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
M. Di Renzo
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10.4236/jbbs.2017.712039 546 Journal of Behavioral and Brain Science
in a two-domain model of social-communication deficits and restricted and re-
petitive interests/behaviors (RRB). Aiming towards a dimensional approach, the
DSM-5 emphasizes the concept of spectrum to reflect a continuum that defines
more accurate and descriptive specifiers
(Severity level; Co-existing conditions
and genetic or medical diagnoses; Intellectual functioning; Language level) that
need a thorough clinical evaluation. The definition of diagnostic specifiers, in
fact, requires the professional, in addition to the use of standardized tests, even a
good expertise in collecting clinical and anamnestic data for being integrated
with the direct observation of the child. The latter, in fact, can never be replaced
by the exclusive use of scores obtained in the assessment process.
It seems clear, in this perspective, the competence that the clinician must have
regard to development and its facets. Otherwise, the risk is to define a diagnostic
framework only for the presence of symptomatic behaviors, without considering
a causal elaboration for each behavior, without highlighting the potential present
and without a precise definition of the areas that need intervention in terms of
priority in the genesis of the disorder.
The observation must then consider the different ways in which the autistic
child expresses his atypia in cognitive, language, behavioral and emotional areas,
to be able to place the therapeutic intervention in the zone of proximal devel-
opment indicated by Vygotskij [2].
In this perspective, the developmental approach, which takes into account all
the components that come into play during growth, can provide the right tools
to deal with the diagnostic and therapeutic process with full respect for the indi-
viduality of each child. The developmental model gives importance to the child’s
motivation to learn and the naturalness of the context in facilitating those nor-
mal tuning processes that form the basis of relationships and therefore of com-
munication [3]-[15].
2. Main Context
This article aims to highlight the importance of adopting a developmental ap-
proach which defines the zone of proximal development so considering the body
dimension as an essential basis to activate the resources of the child and help
him in that attunement process he lacks. This could stimulate a motivating
communication in the child.
The latest developmental and neuroscientific researches show that knowledge
is the result of a process that starts from the bodily-affective area to arrive slow-
ly, and through required steps, to the mental dimension.
Apart from ethiopathogenesis, what we can find in the autistic child is an ar-
rest in the attunement development that determines a serious failure in the imi-
tation processes, a distortion in sensory and emotional processing and, as a re-
sult, a deficit in the cognitive dimension.
The authors of psychodynamic approach, interested in the phenomenology of
the disorder, showed different defensive mechanisms that all refer to a peculiar
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way of experiencing and living the body dimension.
Frances Tustin pointed out that when the autistic child experiences the sepa-
ration from the mother before he has developed the transitional activity de-
scribed by Winnicott, he starts to generate pathological auto-sensuous reactions
instead of expected fantasy, imagination, thought and play [16] [17] [18] [19]
[20].
In the typical early childhood development autistic objects are normal and
gradually give way to the creation of fantasies and illusions and finally to the
thought. In autistic children who instead do not accept the separateness from the
mother, these objects are manipulated in a stereotypical, over-materialized, only
bodily way because these children have never learned to “tolerate” the world as it
is and then to adjust to it. Autistic sensation objects [17] are, therefore, material
objects, “protections” (used in place of the parents and not to evoke their ab-
sence) and are opposed to the development of thought.
The auto-sensuous reactions, as opposed to what normally happens in the
early stages of a child’s life, do not allow to define a bodily boundary because
they are kept alive to divert the attention of the autistic child from everyday ex-
periences. Autistic sensation shapes [18], acting as bodily traces of previous
pleasant experiences, allow the child to console and defend himself from the
sense of loss or abuse of the outside world stimuli.
In recent years Smith [21], with his empathy imbalance hypothesis, argued
that autistic behaviors and stereotypic patterns are defenses the children with
autism develop to manage the excess of feelings and emotions that are not ad-
dressed in the relationship. In this view, the autistic behavior is an adaptive re-
sponse to empathic imbalance. Avoidance behavior, obsessive interests, and in-
sistence on routines may regulate the stress that stems from living among people
whose behavior is difficult to comprehend but whose emotions are all too readily
sensed.
Donald Meltzer [22] described the defensive mechanisms related to the body
through the concepts of sensory dismantling and adhesive identification stress-
ing that the autistic child has a form of primitive permeability which makes him
extremely vulnerable to the outside world. According to the author, autistic
children have a particular speed in mental processes that makes them prone to
perceive stimuli from the outside world as a sort of bombardment.
Through the dismantling, autistic children fragment the experience so to no
longer perceive it as dangerous because this form of segmentation makes im-
possible any form of integration. Since the dismantling is a defensive mechanism
earlier than the splitting, it allows the parceling of the experience which occurs
through the passive attitude of the child and that constantly diverts him from the
relationship with the object. Thanks to the underlying mechanism that is the
adhesive identification, the child is able to adhere completely to the surface of
objects avoiding to perceive the three-dimensionality which gives them depth, so
eluding the experience of limit that anticipates the sense of separateness.
The adhesive identification also provides an explanation of the preference that
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autistic children have for the proximal senses than distal.
The sense of touch, for example, promotes the experience of merging, the ba-
by seeks, whereas hearing or sight confront him with that distance that he would
cancel and that are thus weakened. Fordham [23], considers the autism as a dis-
order of the Self, as a distorted state of integration, owing its persistence to fail-
ure of the Self to deintegrate. Fordham proposed the term deintegration as a
property of the Self behind the ego formation. The Self deintegration is therefore
understood as a normal stage of development in which the child is able to recog-
nize objects as different from the Self (through the physiological process of inte-
gration and deintegration that allows the differentiation of the original psycho-
somatic unity). Reconnecting to immunological researches that discovered the
existence of defensive reactions carried out to cancel or reject the not self-ob-
jects, Fordham assumed that only the objects assimilable from the Self can pro-
mote vital biochemical processes and, in the case of autism, a functional disinte-
gration occurs to hold off the not self-objects, that is a kind of auto-immune
disease that prevents vital processes.
Damasio [24], more recently, showed that the Self
is built in stages, is con-
structed starting from the meeting of the body with the outside world objects,
according to primordial feelings. These are spontaneous reflections of the state
of the living body which form the basis of cognitive processes. The Self comes to
mind from the sensations belonging to the brain stem, which represents, in his
opinion, not a mere conduit for signals, but a first decisional location, a center of
information processing.
The protoself
is an integrated collection of separate
neural patterns that map, moment by moment, the most stable aspects of the
organism’s physical structure, it is a sort of deep root that cannot be alienated.
The knowledge that makes conscious our mind must be built according to a
bottom-up mode, from body to brain. The conscious mind emerges from a link
between the body and the object of knowledge. Primordial feelings, produced by
the protoself, precede all other feelings and uniquely refer to the living body that
is interconnected with its specific brain stem.
According to Damasio [25], in brief, in the cognitive process we can distin-
guish the following steps: 1) an object involves the body when it is looked at,
touched or heard from a specific perspective, 2) the involvement induces a
change in the body, 3) the object’s presence is felt, 4) the object has been made
prominent, 5) the object becomes part of the child’s knowledge and settles in the
memory. The Self, therefore, comes to mind in the form of images that narrate,
without interruption, the story of these entanglements.
What these authors have shown, in physiological or pathological sense, it is
the centrality of the body in child development, hypothesis also supported by
Stern’s studies about inter-subjectivity which highlighted the importance of the
affective attunement. The mechanisms underlying it are the amodal properties
of experience (intensity, time, shape, movement and number) that allow the in-
terchangeability of sensory modes for the different behavioral expressions. What
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characterizes the attunement, distinguishing it from other mechanisms, is its
ability to respond not only to affective categories but also to vital affections such
as the increasing and decreasing of excitement. This possibility guarantees the
continuity of the mother-child experience and allows, in the developmental
process, to experience the vital affections in the form of dynamic changes in
ourselves or in others.
The affective attunement assumes the presence of imitation and contagion
which both express an exclusive interest in overt behavior and which are both
interfered in the autistic children. The child, according to this perspective, is not
able to get the mirroring nor can respond to the variations on a theme that
mother provides him [9] (Stern 1985) because the imitation, already lacking,
cannot favor an adequate affective attunement. Gaddini [26] highlighted the fact
that in the first weeks of life the child perceives through bodily modifications
respect to the object and that the differentiation of perception and memory sys-
tems starts from this early communion of perception and physical imitation.
What Gaddini stressed so bright is the fact that the first manifestations of the
imitation process have to do with being and not with having, so that the imita-
tive conducts can be considered as precursors of the ego adaptation processes.
In this perspective, the autistic disorder consists of a lack or a significant defi-
ciency in the imitation processes that can be defined as a difficulty to pass from
the stage of imitate to perceive to the stage of imitate to be. This is a child’s dif-
ficulty in getting hold, in the sense of Winnicott [27] [28] [29] from the emo-
tional dimension of the mother which is predominantly expressed by bodily di-
mension through the modulation of muscle tone intended as an essential ele-
ment for the transition to the imitate to be.
The tonic dialogue [30] between mother and child, as well as forming the basis
for the future development of empathy, also allows the construction of a plot for
the semantic processing of the contents carried in the relationship. Without the
hug that holds and that allows the child to recognize himself as a separate indi-
vidual there can be no exploration in the world nor the ability to respond to the
other.
More recently Reddy [13], commenting on the imitation studies of Nadel [12],
emphasized the interpersonal dimension already present from the first days of
life with regard to imitation, showing that emotional involvement is essential al-
so for the repetition of those simple gestures, such as tongue protrusion, that
before were seen only through an intra-individual perspective. Many authors
confirmed this hypothesis by moving more and more attention also to the gesta-
tional period as the beginning of possible attunement, so that Trevarthen [5]
coined the term sinus rythm to refer to the existing dialogue between mother
and baby during pregnancy.
Neuroscience highlighted the fact that the inter-subjective characteristic of
first experiences, as well as outlined until now, in the brain is sustained by the
presence of mirror neurons.
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Through the embodied simulation [31] it is possible to experience and then
understand the tactile and painful experience of other people simply observing
them, because even the only others’ observation activates the same neural cir-
cuits that are responsible for others’ feeling. The word simulation is to be un-
derstood as an attempt to mimic the characteristics of a process in order to assi-
milate its essence and is expressed as a modeling mechanism. In this sense it dif-
fers from the process proposed by the “simulation theory” (as a result of a deli-
berate act of will) because it is characterized as an automatic process, not con-
scious and predeclarative.
The classical cognitive approach, which expresses the vision of a fully disem-
bodied human mind, in the sense that the ability to understand others’ inten-
tions would simply be due to met are presentations, appears, in light of this,
simplistic and inadequate to the complexity of the situation [32]. Through the
mechanism of embodied simulation, which enables two different bodies to share
a functional state, the “objectual other” becomes “another self” and thanks to
this it is possible to build the foundations for social intelligence. In this sense the
body, simultaneously perceived as a place of subjective and objective experience,
allows the structuring of that perception of the personality experience that can
be attributed also to the others. The same sensory-motor circuits that control
body movements and perception, in fact, give structure to abstract thought too
[33] [34]. This identity relation, which is transversal to all the forms of interper-
sonal relationships, is defined by Gallese [32] as shared manifold hypothesis and
promotes, as already underlined, the intersubjectivity and the attribution of in-
tentionality to the others. The impossibility of building a we-centric space, as a
basis for establishing a connection with the intentional relations of others, does
not allow the development of a resonance able to favor anticipations of the be-
havior of others. Experimental data on postural attitudes show that autistic
children are not able to use feed-forward mechanisms but essentially use the da-
ta coming from the sensory periphery, unable to adopt anticipatory postural at-
titudes. Experiments with high-functioning autistic subjects showed that recog-
nition and imitation of other people’s emotions occurs through different strate-
gies from those used by normal subjects (there is an absence of the premotor
mirror circuit, underactivation of insula and amygdala and a hyperactivity of the
visual cortex). The lack of embodied simulation does not allow, in this case, to
give an experiential content to the emotions of others and access to the other
would remain limited to the cognitive interpretation of sensory conveyed by an
external event.
In the Italian developmental approach called Turtle Project [35] the focus of
the intervention is constituted from the body’s relationship with the child that
also involves parents in individual and/or group settings. The fundamental ob-
jective is to help parents to interpret the atypia of the child for creating a shared
care that could form the basis for a first form of communication. Meet the need
of the child, as mothers know usually do, is quite different from helping the
child to mentalizing his need. To make this happen it is necessary that adult does
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not refuse the child’s dysfunctional behaviors, as occurs with the use of behavior
modification techniques, but that accept and transform them to kick off that
kind of dance [9] which allows to bring within the context variations on a theme.
Only starting from such tuning can be activate the imitation mechanism that al-
lows the child to imitate to be rather than imitate to perceive.
The reverie capacity [36] [37] of the mother may in fact be reactivated if the
therapist is able to make interpretable for her the child’s behavior and, only in
this case, the mother can start to put in place that hypothesis of semantic nature
[38] [39] [40] which founds other’s mind. The communication starts from the
format [41] that is established within the context when the mother, regardless of
the intention of the child, can give a meaning to his actions because it is only the
mind of the other which can found in the autistic child a mental state that makes
him a talking of his native language.
In Turtle Project [35] dyadic therapy is privileged just to allow a new form of
relationship that helps the child to live the dependence in a new form and to
learn new patterns of communication. Unlike what happens in other approach-
es, the therapist is an active part in the interaction, a living companion [42] act-
ing as a facilitator for communication and as a model to be imitated by parents
who do not yet know how to respond and interpret the mainly bodily child’s
messages. The therapist is there, as Winnicott would say [43] [44], where the
child can meet him, and helps the mother-child pair to tolerate the inevitable
frustrations that arise from the difficulties in finding an attunement. An attune-
ment which applies only to that child who is in relationship with his mother, and
not to a couple in an abstract sense, because every relationship is unique, and
each individual is what becomes according to the personal patrimony and in
reference to the stimuli received from the environment. Learn to tolerate the in-
evitable frustrations necessary to find the same significance to the events is what
founds the profound sense of language and that allows the learning of meanings
shared by the community.
In a general sense the aim of the developmental approach of Turtle Project is
to create natural settings in which to support, through a bodily intervention, the
developmental trajectories of each child, helping him to integrate the various
senses and to meet the body of other people without being afraid of.
In this sense, besides the dyadic therapy, group interventions are proposed to
enable the embodied simulation with peers in motivating contexts where the
mirroring of dysfunctional behaviors acts as a further stimulus to attune. In the
peer group supported by therapists (at least 2 professionals to 4 children) the
child find a natural framework in which give shape, that is format [41] contents
not yet integrated and where, at least initially, also the dysfunctionality can be-
come an adaptive form if the others can understand or share it. The objectives,
calibrated for the single group, are gradually modified to allow more structured
communication layers and the expansion of language occurs as the child’s need
to exchange and not for imposition from outside. In this way, also the modeling
that the therapist puts in place to improve the linguistic expression is accepted as
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main driver of the relationship and not as incomprehensible claim for a perfor-
mance.
Once the child is able to find a good level of attunement with the outside
world, it is possible to propose him more structured interventions that support
the cognitive development with modalities more advanced than those necessary
to be present to the other in an affective relationship.
To demonstrate how the bodily-affective dimension is crucial in the structur-
ing of the autistic disorder and how it takes priority over the cognitive dishar-
mony some studies [45] [46] [47] [48] highlighted, through the evaluation pro-
tocol called T.U.L.I.P.1, how a sample of 49 children, regardless of the ADOS
score [49], showed a better ability to understand intentions and emotions of the
others. By monitoring the group during 4 years of Turtle Project therapy [35]
there was evidence that the results were significantly better as early as the end of
the second year of therapy, compared with children who had a worse outcome at
the T.U.L.I.P. protocol testing. As well as allowing the identification of the zone
of proximal development, the T.U.L.I.P. protocol clearly shows that the main
obstacle to the development is determined by the lack of those basic attunement
mechanisms that are highlighted through the UOI and the TCE [47].
This approach requires, as can be seen from the above reflections, a therapist
competence both in the field of the development theories to calibrate the inter-
vention according to the developmental level of the child, both in the relational
area in order to contain the anxieties, the frustrations, the attacks on linking
[36], the atypical behavioral that dot the intervention with parents too. That is
why in Turtle Project approach there are psychotherapists of developmental age
and professionals with specialized developmental relationship training.
3. Conclusions
This theoretical and clinical framework allows to elaborate also the emerging
difficult emotional dynamics. The knowledge of the technique itself is not suffi-
cient to guarantee the capacity to hold child’s and own’s reactions, because the
risk is to put in place aggressive behaviors to evade the sense of impotence felt.
The rigidity of some methods colludes with the persistence of the child to pro-
tect himself from the outside and amplifies his obsessive behaviors giving rise to
an unsuccessful escalation which can be transformed only if profoundly elabo-
rated by the therapist. It is not useful to answer the segmentation with a symme-
trical behavior because the primary goal is to encourage a possible integration.
On the other hand, the indispensable premise of the intervention is starting from
the child and not from the symptoms present, this to ensure, besides the change,
also his right to childhood. The starting point is always the body as a place of
primordial feelings that need to be gathered, accepted and elaborated from the-
1The
T.U.L.I.P
. protocol investigates the autism severity through the ADOS, the IQ through the Le
i-
ter-R, the ability to understand the intentions of others through the Understanding of Other Inte
n-
tion (UOI) test and the
presence of emotional contagion through the Emotional Contagion Test
(TCE).
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rapist’s mind in order to share and mentalize experiences.
It appears necessary, especially in the early stages of therapy, that the inter-
vention is not fragmented among different operators and disciplines because this
would collude with the already existing fragmentation of the child and his con-
text while therapists must act as facilitators in all directions. Multiple operators
may work in the Turtle Project approach because they all perform the living
companion function. This activates the existing resources by channeling the
energies of the child towards the next stage of development without having to
distinguish too early the psychomotor intervention from the speech therapy, be-
cause the child needs to integrate his knowledges at the time when he lives them,
so the words acquire their deep meaning if they arise from the action and if are
shared in the play. The ludic dimension, that is to play and do not play games, is
what should characterize all interventions so that enjoyment and motivation
could activate the cognitive functions. To get involved is what promotes the ac-
tivation of the ludic area that should never be confused with the use of games for
educational purposes but is constituted by shared action that generates pleasure
and encourages to look for the other, in order to avoid those self-stimulations
which, in absence of other, allow the child to experience few moments of rest. In
a research conducted to assess the efficacy of the developmental approach [35],
in a sample of 80 autistic children, significant improvements were founds in all
developmental areas: significant change was found on Cognitive abilities (F2, 78
= 32.06, p < 0.001;
η
2 = 0.29); on ADOS score (F2, 78 = 65.15; p < 0.001,
η
2 =
0.45); on Stereotyped behaviors (Wilks’ lambda: 0.76; p < 0.001,
η
2 = 0.24). In
fact, after 4 years of therapy, 31 children (39%) came out from the ADOS diag-
nostic category of autism, and 14 children (15%) changed ADOS diagnosis from
autism to spectrum. The other children, although remaining in the same ADOS
diagnostic classification, showed a decrease in the ADOS score and consequently
also in the autistic symptomatology for all the areas taken into account (com-
munication, reciprocal social interaction, play, restricted and repetitive beha-
viors). Another significant finding emerged from the research in question, was
the increase in IQ score in the most of the children (%) which showed that lo-
wering the defenses and growing the relational opening, if realized through an
intervention that uses the body in the rehabilitative relationship with the child,
make it possible a better use of the cognitive potential.
In light of the foregoing, it would be advisable that the bodily dimension was
more considered in the treatment of children in the autistic spectrum and that it
was given greater importance to the psychomotor area during the assessment
and naturally during the therapeutic process.
The future perspective of therapies for children with autism spectrum disorder
should therefore be to promote more and more the attunement processes that
involve the body as a place of primordial affection and feelings. The inter-
changeability of sensory modes, activated by the attunement processes, in fact,
supports behavioral expressions paving the way for the structuring of cognitive
processes. If the child has been able to experience the various sensory elements,
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learning how to adjust depending on interaction with each other, he will have
the tools needed for solving the problems that world experience requires.
Cognitive maturity, as Bruner points out [50], depends on the relationship of
enactive, iconic and symbolic systems of representation.
Compliance with Ethical Standards
All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or national research
committee and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards.
Informed Consent
Informed consent was obtained from all individual participants included in our
previous studies and citated in this paper.
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Abbreviation Note List
Pervasive Developmental Disorders (PDDs)
Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5)
Restricted and Repetitive Behaviors (RRB)
Emotional Contagion Test (TCE)
Understanding of Other Intention (UOI)
Leiter International Performance Scale-Revised (LEITER-R)
Autism Diagnostic Observation Schedule (ADOS)
TCE, UOI, Leiter-R as Indicators of Predictivity (T.U.L.I.P.)