Academic journal article American Journal of Psychotherapy

An Outpatient Treatment Program for Young Children with Pervasive Developmental Disorder

Academic journal article American Journal of Psychotherapy

An Outpatient Treatment Program for Young Children with Pervasive Developmental Disorder

Article excerpt

During the past three years I have had the opportunity to assess and treat about 14 children under the age of 3-1/2 years who suffered from pervasive developmental disorder (PDD). This is a relatively large number of cases seen by a child psychiatrist not working in a specialized setting for these children. PDD is a rare disorder, with an incidence of 4-8 in every 10,000 children.(1,2) This clinical exposure challenged my understanding of this disorder. It also modified my pessimistic attitude toward working with these children in an outpatient setting. In addition, other practical and intellectual factors led me to try working with seven of these children on an outpatient basis. (The other seven were involved in other programs, or the parents were not interested in treatment.) The practical factor was the absence of facilities for such young children, the result of funding cuts to health services and of laws that aim at keeping children in regular public school classes and encouraging a community-based approach to working with them. The intellectual factors were twofold: a change in the way we conceptualize infancy and a change in our understanding of the nature of PDD.

My exposure to these children led to two major observations. The first was that a main criterion associated with this disorder, described by the term "autistic," did not apply to them. Even though DSM-III-R includes phenomenological criteria, maintaining the name "autistic disorder" still implied autistic behavior: withdrawn, aloof, or "in an eggshell." Most of the children I saw did not exhibit this characteristic. These children were attached to their parents and related to them and their environment in an often bizarre way, but they related nonetheless. This disorder is probably better viewed as one of interpersonal relationships. My second observation was that the children responded to clinical interventions based on an understanding of their developmental stages and needs and designed to maximize normal interactions. The following vignette illustrates this observation:

VIGNETTE 1

Tom was two years old when assessed and fit the diagnosis of autistic disorder, according to the DSM-III-R. He showed no imitation, social play, or interest in making friends. There was no verbal and little nonverbal communication; instead, he occasionally uttered loud squeaky noises. He looked dazed, avoided eye contact, flapped his hands, twirled, and put all objects into his mouth. His mother indicated that she had rarely interacted with him since his infancy. She was a sine working mother and slept when she got home from work, letting Tom roam the apartment by himself. Very early, I recommended that mother should play and interact more with Tom. A few sessions were spent helping her to do that.

Approximately three months later, the mother reported, and I observed, significant changes in Tom. During one session, I saw him with his mother and noted the following changes. His glazed look became less glazed, and he established more eye contact. His twirling, hand-flapping, and squeaky noises decreased. He played more with his mother and started to communicate nonverbally by pointing at what he wanted. However, later the same day when I saw Tom with his father, I noted a dramatic change. The father did not live at home but visited Tom frequently. He was clearly disappointed at how Tom had turned out and was rather harsh with him. Father would hold Tom's hand to prevent him from sucking his thumb and hold him in bed to stop his twirling. Mother indicated that Tom ran away and hid when father visited. During the session with father, Tom's behavior regressed to that observed initially. After a while, father became more hostile to me and refused to play with Tom. At that point, Tom came to me, raised his arms indicating his wish to be picked up, and then sat on my lap hugging me and sucking his thumb. This case, and the others, clearly illustrated that these children were not autistically withdrawn, but responded to their environment, even if they showed the signs and symptoms of autistic disorder. …

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