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(Article 2)​ Facilitating attachment in children with autism through art therapy: A case study. By: Huma Durrani Inside Out ​Art​ ​Therapy​, Singapore​; Acknowledgement: Children​ with ​autism​ display a large spectrum of function and dysfunction ranging from having amazing talents to severe challenges. However, a common thread runs ​through the symptomology of ​autism​ spectrum disorder (ASD). Those suffering from this disorder are characterized by impaired social interaction, sensory dysfunction, self-regulatory issues, limited interests, and repetitive and rigid behavior (​American Psychiatric Association, 2000​). ​Autism​ is often also associated with other disorders, such as anxiety, depression, attention deficit disorder, and motor incoordination or dyspraxia (​Baron-Cohen & Belmonte, 2005​; ​Hill & Frith, 2003​). Studies​ of early development of ​children​ with ​autism​ are limited. This is because autism​ is generally diagnosed around 2 years of age, when autistic symptoms become more apparent (​Volkmar, Chawarska, & Klin, 2005​). Research in the last century has mostly relied on parental observation of ​children​ and retrospective reviews of videotapes and home movies. However, as the importance of early diagnosis and intervention has become evident, some longitudinal ​studies​ have emerged (​Volkmar et al., 2005​). Because of the complexity of the syndrome, there is no typical course of early childhood development in the autistic ​child​. Although a stereotypical ​child​ passes ​through normal stages of early childhood development relatively easily (​Klin, Lin, Gorrindo, Ramsay, & Jones, 2009​), development of the ​child​ with ​autism​ is marked by the emergence of two core features of ASD: sensory dysfunction and impaired self-regulation. Because sensory dysfunction affects the auditory, visual, vestibular, tactile, and proprioceptive areas in varying degrees depending on the particular autistic child​, considerable symptom heterogeneity naturally presents among ​children​ with autism​. This results in a wide range of individual differences in impairment along the autistic spectrum and unique sensory profiles among autistic ​children​ (​Brock et al., 2012​; ​Dunn, 1999​). Therefore, although a capacity for self-regulation in typically developing normal ​children​ occurs because of maturing executive functions and interaction with the environment, ​children​ with ​autism​ suffer many self-regulation



difficulties. These range from disturbed sleep patterns to impulsivity, irritability, and hypersensitivity. All of these sensory difficulties may play a role in inhibiting the social and emotional development in the autistic ​child​ that is dependent on positive interaction with the environment (​Gomez & Baird, 2005​). In addition to the development of sensory integration/functioning and self-regulation, a core feature of normal early childhood development is the ability to attach to a caregiver. This ​attachment​ has been hypothesized to lay the blueprint for future relationships in later life stages (​Bowlby, 1951​). Forming in the first year of life, attachment​ quality is determined by the interaction of the infant with his or her caretaker and is dependent on attunement between both parties (​Howe, 2005​). A ​child with sensory dysfunction often blocks sensory input from the environment as a defense against unpleasant sensations that cause anxiety and distress (​Gomez & Baird, 2005​). One could argue that such sensory dysfunction and self-regulation difficulties limit the autistic ​child​’s capacity to benefit from attuned others, which in turn may result in a child​ with ​autism​ suffering from an impaired capacity to attach to caregivers and being impeded from optimal communication and exchange with the environment. All may limit the autistic ​child​’s availability for ​attachment​ in his early years (​Gomez & Baird, 2005​) and negatively affect the ​child​’s subsequent development in areas of communication and emotional development. A ​study​ conducted by ​Seskin and colleagues (2010)​ using the “strange situation” and its variants shows that although ​children​ with ​autism​ can form secure ​attachments​ with their caregivers, insecurely classified ​children​ with autism​ outnumber the securely attached ​children​ without ​autism​.

Aim The aim of this paper is to illustrate the role that ​art​ ​therapy​ may have played in facilitatingattachment​ and social functioning in a young autistic boy, Tom. Because ​art therapy​ is a multisensory, multifaceted approach, it can be tailored to the individual needs of a particular ​child​ with ​autism​. ​Martin (2009a)​ has highlighted treatment goals of ​art​ ​therapy​ with autistic ​children​ to include communication, socialization, early intervention, and sensory regulation. We argue that ​through​ multisensory ​art​ activity and attunement with the ​art​ therapist in a safe holding space, ​art​ ​therapy​ beneficially affected Tom’s sensory dysfunction and self-regulation difficulties. ​Through​ lowering his anxiety levels, a more self-regulated Tom may have become more able to form an attachment​ with the ​art​ therapist. ​Attachment​to the ​art​ therapist might then have provided Tom with an experience of a substantial human bond similar to a normal



mother-​child​ relationship or ​attachment​ to a primary caregiver—a bond that is critical for a healthy psychoemotional development in a ​child​.

Literature Review Autism Autism​, a term not commonly understood a few decades ago, is now a familiar developmental disorder with known worldwide prevalence. ASD is diagnosed based on a core triad of clinically observable symptoms that involve impaired social interaction and communication abilities as well as the presence of restricted, repetitive, and stereotyped behaviors and interests (​American Psychiatric Association, 1994​). According to ​Hill and Frith (2003)​, ​autism​ varies in severity, and it is modified by many factors, including education, ability, and temperament. ​Autism​’s clinical picture can also change over the course of development within one and the same individual. In addition, autism​ is frequently associated with other disorders, such as attention deficit disorder, motor incoordination, sensory dysfunction, and psychiatric symptoms such as anxiety and depression. Contemporary research implicates environmental factors together with genetic susceptibility as the probable cause of ​autism​ (​Martin, 2008​).

Sensory Dysfunction and Self-Regulation Difficulties in ASD One of the central characteristics of ASD is dysfunction in the sensory processing system of the autistic ​child​. Many ​studies​ provide evidence of abnormal sensory processing in individuals with ​autism​(​Baranek, Foster, & Berkson, 1997​; ​Kern et al., 2006​; ​Liss, Saulnier, Fein, & Kinsbourne, 2006​; ​Tomchek & Dunn, 2007​). The sensory system or sensory organs and the autistic individual’s senses of sight, hearing, smell, touch, and proprioception process diverse input from the environment in an atypical way. According to ​Greenspan and Weidner (1998)​, when some part of the sensory system goes awry, it causes dysfunction. Most ​children​ with ​autism​ have this sensory dysfunction. In some autistic ​children​, one sense may be more affected than others. Greenspan and Weidner (1998)​ elaborate and explain that “these systems enable us to feel balanced and safe as we move, sit, and stand, to let other people get close, and to protect ourselves if we feel endangered” (p. 36). They suggest that normal sensory functioning is required for normal social functioning. Human beings are continually exposed to input from the environment during development. Therefore, it is inevitable that an autistic ​child​ with sensory dysfunction will have difficulty regulating their interaction with their surroundings. Interaction with the environment might lead to a sense of heightened anxiety in the autistic ​child​. Because of this unpleasant



experience, the ​child​ is likely to withdraw from the environment to limit their sensory input. Hence, this withdrawal from the environment also leads to distancing from relationships and subsequent impairment in the psychoemotional development of the child​ (​Gomez & Baird, 2005​). Gomez and Baird (2005)​, listing four levels of self-regulatory development, cite attachment​ as the second level that occurs between the ages of 2 and 7 months. We argue that in ​children​ with ​autism​, the need to self-regulate sensory discomfort by withdrawal hampers social and emotional development and leads to impaired interaction with the environment. A personal account of these difficulties is offered by Temple Grandin, a well-known personality suffering from ​autism​, who has referred to the social and emotional consequences that resulted from defects in her own sensory system. She described how painful her overwhelming auditory experience was and how impossible it was for her to think about emotions when all she could do was protect herself from the onslaught of terrible noise (​Grandin & Scariano, 1986​). We hypothesize that the normally rich ground for developing relationships becomes impoverished for the ​child​ with ​autism​ mainly because of their sensory processing difficulties. By not being able to regulate overreactive or underreactive responses to sound, touch, vision, smell, and proprioception, the autistic ​child​’s capacity to connect to others is interfered with as they experience sensory deregulation and immense anxiety (​Gomez & Baird, 2005​).

Attachment Attachment​ theory emerged from the joint work of John Bowlby and Mary Ainsworth, who were in turn both influenced by the work of Freud and other psychoanalytic thinkers. According to ​Bowlby (1951)​, a mentally healthy infant “should experience a warm, intimate, and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment” (p. 13). Referring to this as a mutual regulatory system, ​Arrington and Cherry (2007)​ state that the “system unfolds when activated by certain cues and conditions from either the mother or the infant. A mother who provides a fragile infant with consistent feelings of safety ​through​ sensory experiences of gentle touch, warm liquid, a motherese voice, and presence, builds core states of well-being while reducing anxiety, fears, sadness and stress” (p. 29). According to ​Howe (2005)​, a safe and secure ​attachment​ is a biological means of survival and a means of controlling anxiety. ​Prior and Glaser (2006)​ add that attachment​ is “based on the need for safety, security and protection” (p. 15). From a dynamic perspective, the first ​attachment​ relationship is considered crucial to the establishment of a secure base for the ​child​ and his or her future relationships (​Bowlby,



1951​). Therefore, any disturbance in the infant’s ​attachment​ to the mother may have undesirable long-term consequences for the ​child​ throughout his or her life. Attachment​ may be classified as secure or insecure (​Wood, 1984​). Insecure individuals may suffer from anxiety in their ​attachment​ relationships and find it difficult to regulate their anguish and arousal (​Howe, 2005​). Research on ​attachment​ and ​autism​ shows that although ​children​ with ​autism​ are able to form secure ​attachments​, the parent-​child​ relationship for an autistic ​child​ and their caregiver often “reflects less flexible, sensitive, and synchronous interactive behaviors as a result of the social impairment of ​children​ with ​autism​” (​Rutgers et al., 2007​, p. 860). ​Naber and colleagues (2007)​ support these findings, adding that these relationships are greatly hampered by developmental delays and arousal difficulties. Therefore, there is evidence that points to a relationship between ​autism​ and disrupted early ​attachment​.

Art Therapy: A Brief Introduction Art​ ​therapy​, a relatively young profession, was “born” in the second half of the 20th century. It was developed by individuals, mostly artists themselves, who believed in the healing power of ​art​-making and imagery. In the early 20th century, thinkers such as Sigmund Freud theorized the emergence of the unconscious ​through​ imagery and dreams. Karl Jung also proposed his theory of the collective unconscious as one that was rooted in symbolism and imagery. Both psychoanalysts, Freud and Jung, realized the inadequacy of language in reflecting our inner, emotional world. ​Art​ ​therapy developed from the idea that the process of image-making and creative expression heals and transforms unpleasant life experiences ​through​ symbolic communication (​Malchiodi, 2002​). As the profession grew, it borrowed theoretical knowledge from the counseling and psychotherapy disciplines to enhance the clinical skills of ​art​ therapists. Although ​art therapy​ has its roots in psychoanalytic and psychodynamic theory, it has since embraced other philosophies and approaches, such as cognitive ​art​ ​therapy​, Gestalt and Jungian existentialist ​art​ ​therapy​, and narrative or phenomenological ​art​ ​therapy​. Art​-making remains central to the practice of ​art​ therapists who enrich their understanding by integrating knowledge from other disciplines (​Moon, 2002​; ​Vick, 2012​). The fundamental belief that underpins ​art​ ​therapy​ is that ​arts​-based mediums and the creative process all possess inherent qualities of healing that can access and affect unconscious processes inaccessible ​through​ verbal forms of expression.

Art Therapy and ASD It is well established that ​children​ with ​autism​ lack the innate drive to communicate or interact with others and may even reject attempts by others to communicate orally.



Therefore, the drive to connect to others needs to be roused before developing other facets of communication (​Osborne, 2003​). Art​ ​therapy​ is a means to arouse communicative drives within the autistic ​child​ who, according to ​studies​, may find processing objects easier than faces, “so in theory the art​ object may be more useful than the adult’s words” (​Martin, 2009a​, p. 74). Art​-making can also be fun and provide leisure while achieving developmental goals (​Martin, 2009a​). Martin adds that “sensory regulation is often less stressful for the client in ​art​ ​therapy​ because the ​art​ provides a product to focus on beyond the process of integrating uncomfortable sensory experiences” (​Martin, 2009b​, p. 188). Adding to that, Emery (2004)​argues that

The use of nonverbal expression through the experience of making art encourages children with autism to begin to represent their experiences. Forms represent objects and the very act of drawing with intention may encourage attachment to the object. Children create art because it is rooted in the need to relate to their world. (p. 147) Art​ ​therapy​ may also facilitate the autistic ​child​’s awareness of self ​through relatedness with the artwork. This may again help in developing object constancy because of the concrete nature of the artwork that can be remembered and referred to over time (​Emery, 2004​; ​Martin, 2009a​). Because ​children​ with ​autism​ also often suffer from significant deficits in the areas of language and communication, ​art​ ​therapy​ as opposed to language-based approaches may offer the ​child​ with ​autism​ a more befitting therapeutic modality. Art​ ​therapy​, a nonverbal form of creative expression, has been used to help individuals from many age groups heal and find relief from mental health problems, gain insight, achieve personal growth, find relief from emotional conflict, resolve issues, and increase their sense of well-being (​Malchiodi, 2012​). As a modality, ​art​ ​therapy​ makes use of a wide range of ​art​ materials with visual and tactile diversity. As such, ​art​ ​therapy​ can offer various means to engage the senses of sight, hearing, touch, smell, and proprioception, potentially encompassing the entire range of the human sensory experience. A large variety of media in a wide spectrum of colors and textures may be used as a means of sensory regulation for the tactilely hypersensitive or hyposensitive child​. Clay, paint, goop, sand, and/or play dough may be manipulated, beaten, and stretched to provide proprioceptive input. Music can also accompany ​art​-making to target the auditory areas. Different materials such as tin foil, bubble wrap, or Styrofoam can be crushed or pressed to produce various sounds. Scented paint, pencils, crayons, and glue engage the sense of smell. Art​ ​therapy​ also has the potential to adapt to the variability of individuals presenting with unique profiles of ​autism​ whether they are verbal or nonverbal, able or disabled, resistant or willing. This is because the scope of ​art​ ​therapy​ is wide. The variety of



material available for artwork and a range of techniques can be tailored to the needs of the hypo- or hypersensitive ​child​. Because each ​child​ with ​autism​ has a varied and individual sensory profile, an ​art​ therapist needs to be familiar with an autistic individual’s particular profile(s) to prudently use the ​art​ material. This would necessitate working in collaboration with the ​child​’s occupational therapist to better understand the child​’s sensory issues or to have access to the ​child​’s developmental and psychological assessments if they are available. Important questions that would need to be answered would relate to the ​child​’s sensitivity and reactivity toward particular sensory input. The therapist who is familiar with the sensory profile of an autistic ​child may be able to open the door to communication and relational development. Because of its concrete and visual nature, ​art​-making can also aid a client with ​autism by offering avenues of expression that are potentially soothing. This is because the individual can engage in alternative, yet still sensory, modes of repetitive artistic expression. Current ​art​ ​therapy​ approaches with ​children​ with ​autism​ are believed to provide a venue for the autistic ​child​’s self-expression and self-regulation and to provide nonverbal visual tools to facilitate social skills and communication. According to Martin (2009a)​, ​art​-making may satisfy an innate aestheticism in these ​children​ in addition to providing channels for their self-stimulatory and repetitive behaviors. She adds that “lack of imagination and abstract thinking skills is one of the three major deficits of ​autism​ yet is the one least often addressed by most therapists; ​art​ therapists have a unique ability to improve these skills” (​Martin, 2009b​, p. 188). Through​ attunement of the ​art​ therapist and the ​child​’s own sensory experience, autistic ​children​ can also improve their imitation skills, motor skills, and coordination. These skills can further bolster emotional awareness and understanding, emotional regulation, and social skills (​Gabriels & Gaffey, 2012​). Gilroy (2006)​ enumerates several ​studies​ conducted by ​art​ therapists with ​children​ on the ​autism​spectrum using ​art​ ​therapy​ as an intervention. These ​studies​ also support the efficacy of ​art​ ​therapy​ in the social, behavioral, and developmental areas of the child​ (​Evans & Dubowski, 2001​; ​Henley, 2001​). More empirical ​studies​ on ​art​ ​therapy for ​autism​ are still called for. According to ​Gomez and Baird (2005)​, most of the research in ​autism​ has been in the areas of sensorimotor development, communication, and cognitive and social aspects, and it has been done retrospectively. Most ​therapies​ for ​children​ with ASD focus on the cognitive and behavioral aspects of the disorder, often neglecting the psychological implications for development. As such, research concerning social and emotional development is rather limited.