Saturday 14 April 2012

Is autism primarily a disorder of interpersonal relatedness?

A short post today in response to a new piece of research that adds weight to a major theoretical plank that underpins Relationship Development Intervention (RDI) as an intervention for autism.  

'The Cradle of Thought' by Peter Hobson develops the proposition that autism is a disorder of interpersonal relatedness: something interferes with brain development early in life which derails the typical developmental process.  In typical development, we know that flexible, adaptive thinking (and therefore flexible, adaptive behaviour) develops through the social interaction (interpersonal relatedness) between the child and his/her caregiver.
One of the many things that I like about the Hobson hypothesis is that it gives us a unifying theory for the triad of impariments: good social interaction, communication and flexibility of thought and behaviour all develop as a result of the interpersonal engagement that takes place between child and caregiver in the early years.  Studies in the fields of child psychology and child development have shown us that social referencing, joint attention, joint engagement, theory of mind, executive functioning, perspective-taking, the 5 stages of intersubjectivity and many more key thinking competencies all develop as a result of this interpersonal engagement in the early years.  

Without mastery of these developmental milestones, there will inevitably be impairments in social interaction and communication plus rigid and repetative behaviours.  These milestones are what enable us to take different perspectives, understand others, contrast our thinking to theirs, think flexibly and to cope with (and enjoy) change and uncertainty.

Earlier today I was introduced to a study (thank you fellow blogger Paul Whiteley) 'Reversible autism and intellectual disability in children' which appears to provide further support for the theory of autism as a disorder of interpersonal engagement.

I was particularly struck by the evidence in the study for early institutionalisation and blindness as 'causes of autism in a minority of cases' and the 'reversibility of autism' in these cases.  The 'Cradle of Thought' also studies children from these sub groups.  In 'Cradle', in the majority of cases of children in these sub-groups, children no longer met the diagnostic criteria for autism when the institutionalised children (who suffered social deprivation in the orphanages of Romania) were re-habilitated (via interpersonal engagement) and when the blind children found ways to link with other people on a personal level (lack of sight was found to be a major impairment to interpersonal engagement.)

I think what this tells us is that the triggers for brain disrpution that lead to autism may be many and varied, but these triggers seem to result in a similar outcome - the derailment of the typical pathway of development......a chain reaction of missed developmental milestones  that eventually leads to a diagnosis of autism.  If a child doesn't master social referencing (looking to see what a guide or communication partner thinks about something and then using the partner's thinking to direct their own action), s/he definitely won't go on to master the initiation of joint attention (directing a social partner's attention towards an object with the purpose of sharing thinking/feelings about the object).  Without joint attention, there can be no joint engagement (active and sustained involvement in a joint activity with the intention of sharing experience/emotion).  

Here is a clip of me and Philip from 2008 tidying the train track that shows both joint attention and joint engagement.  I can't get the video to embed in the blog, so am having to provide a link instead :(

There is some good joint attention e.g. at 0.34 when we both look at the track tub as we throw our pieces in, then look at each other to share our emotion about our success in 'getting a turkey' (three pieces in a row).  Joint engagement happens throughout the interaction - notice how much Philip is enjoying our pattern of throwing pieces in at the same time and enjoying the variations we do around this.  Both if us are varying the pattern and we can see that he is emotionally invested in this (enjoyment, smiling, feelings of competence) and therefore motivated to keep going with the activity.

When children fail to master all these fancy-named higher level thinking competencies, we are left with children and adults who often get 'stuck' in their thinking and who crave routine and sameness.  It is a developmental domino effect.

I think the research also tells us that with the right intervention (as above, social interaction that fosters interpersonal relatedness) some children who initially meet the criteria for autism will no longer meet these criteria.

The finding that autism is reversible in these cases screams out (in my view) that it is social communication interventions which support the development of interpersonal relatedness that should be the priority for autism research.


  1. You are on the right track and it is interesting to name RDI-a therapy that someone somewhere wants to name and make money on when nearly everyone with an Autistic child can write volumes on the inability or low ability to master relationships. What is missing is the PHYSICAL- not mental or psychiatric components of these chemically injured children because of the toxins mercury, embalming fluid, formaldehyde, polysorbates. Let us pull this altogether. Many can be recovered once we acknowledge all of the layers of damage they were afflicted with. Detox the poisons, add the early therapies, teach the phonics, add the vitamins that their bodies can not process and then the children can get well; the subject of my upcoming book.

  2. I dont agree that RDI is primarily a money making venture or that profit (or what looks like an insinuation of exploitation) was the motivation for developing it. The folk who created it invested their own money in its development and they continue to reinvest in its ongoing development. They make a living out of it, but its not made them rich.
    Most RDI Consultants struggle to actually make a living out of it, unless they are double trained (eg as Speech and Language Therapists, Psychologists etc). I dont know any RDI Consultant who is able to make a living out of RDI alone.
    I dont really understand your difficulty with the creators of RDI making a living from something they developed to help families of children with autism.....unless you have evidence that the motivation for the development of RDI was/is to make money out of families. If you do have this evidence, I would be pleased if you would share it. If not, then your comments are based on assumption and bias.
    Parents may be able 'to write volumes on the inability or low ability of their children to master relationships' but writing about a child's difficulties doesnt get anyone anywhere unless it is also accompanied by a strategy to help address those difficulties - which is what RDI provides.
    I'd be interested to see the evidence showing how many and which children have been 'recovered' with biomedical interventions, early therapies and phonics. I would want to see not only evidence that their metabolic profile has improved but also that their social communication and dynamic thinking has improved. I would want this to have been judged by blind testers using standardised tests.
    I agree that environmental insults such as the ones you quote (and many others) can trigger autism in some (perhaps many) children but I dont agree that simply treating the nutritional deficiencies and detoxifying the toxins is enough to lead to all children with autism no longer meeting the diagnostic criteria for autism. As it states in my blogpost, we know that flexible, adaptive thinking develops as a result of the interpersonal engagement that takes place in the early years. If we address the environmental insult that triggered the autism, that doesnt somehow automatically magic all that missed early interpersonal engagement into place - there are still going to be holes in the development of thinking because the interpersonal engagement that develops it has not taken place.
    I do agree that all children with autism should be metabolically tested and treated - gut, immune system, nutritional deficiencies and ability to detoxify. I think this is part of the answer but my focus is more on the development of thinking as the major part of the answer to the difficulties at the heart of autism.

  3. How does all this fit in with reflex integration that so successfully helped my autistic son?

  4. Hi Motivatedmum

    Excellent question! I'm not going to attempt to answer that because its outside of my area of expertise. Funnily enough, I've recently asked a colleague of mine who works in the field of reflex inhibition and integration to write a guest blog post on exactly the question you are asking. So I'm really hoping she will agree. Watch this space for further info.