a psychoanalytic approach to language delay

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A psychoanalytic approach to language

delayWhen autistic isnt necessarily autism

CATHY URWINLondon

Summary This paper describes family work with four children from different ethnic backgrounds

presenting with autistic features in the context of delayed or deviant language development and, in one

case, elective mutism. It begins by describing how psychoanalytic approaches to language development

have tended to see the process as underpinned by symbol formation as a compensation for loss of the object.

This is contrasted with an approach which, following Bion, emphasizes language development as an aspect

of a broad process concerned with enabling emotional experience to become thought. I also emphasize the

signicance of the survival and development of the self in achieving separation. In the case studies,

the paper highlights the degree of trauma in the parents backgrounds, which had impeded them from

containing their childrens developmental anxieties. The parents telling their stories was both valuable

to them and enabled them to become more emotionally available to their children. In all cases the work

promoted language development and autistic features disappeared or waned considerably after relatively

brief intervention. The conclusions discuss the relevance of these ndings to the autistic child population,

and the value of child psychotherapy to differential diagnosis within the autistic spectrum.

Keywords Autistic spectrum; language development; language delay; multicultural; trauma.

This paper comes from a long-standing interest in language development as anemotional process, and from a concern over the growing number of pre-school chil-dren with autistic features referred to our clinics. How can child psychotherapistscontribute positively to the assessment and treatment of these children, where childpsychotherapy is not possible or appropriate?

I begin by contrasting different ways of conceiving language development psycho-analytically, before describing family work with four children from different ethnicbackgrounds referred for severe language delay and autistic features, which disappeared

after relatively brief intervention. I emphasize the signicance of traumatic aspectsof the parents backgrounds, and the rather active approach I took to reach parts ofeach child that had gone missing. I conclude by discussing the relevance of this workto the autistic child population as a whole.

Journal of Child PsychotherapyISSN 0075-417X print/ISSN 1469-9370 online 2002 Association of Child Psychotherapists

http://www.tandf.co.uk/journalsDOI: 10.1080/00754170110114800

JOURNALOFCHILDPSYCHOTHERAPY

VOL. 28 NO1 2002 7393
http://www.tandf.co.uk/journals


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Psychoanalysis and language

Language is central to psychoanalysis; it is after all the talking cure. Yet, surpris-ingly, little attention has been given to how we acquire it. Most approaches stressits signicance in dealing with separation, absence and loss. For example, probablythe most extensive account is that of Lacan, for whom the acquisition of languageis part and parcel of the Oedipus complex. In identifying with the father, or acceptingthe centrality of this position, the child takes on board the language of the commu-nity as a cultural requirement, with repression as an inevitable cost (Lacan, 1966).

An earlier step in this process is illustrated by what Lacan called the fort-da, thecotton-reel game, described by Freud (1920), as invented by an 18-month-old boychild struggling to separate from his mother. The game consisted of throwing awaya cotton reel with a string attached, the child uttering oo!, recognized as a babyishcorruption of fort! the German for gone!, before joyfully pulling it back, with da!,

the German for there!. While Freud gave many interpretations of this game, Lacansaccount stresses not only a symbolic annihilation of the mother but also how thesymbolic substitution through the use of the words from the cultural register, fort-da, cuts the child off from the object of his desire. For Lacan, language is createdaround this ever-open gap, and contains this loss within it.

This emphasis on loss or cost involved in language development is also found inSterns (1985) more recent account of the verbal self. Stern is well acquainted withthe pre-verbal communication research which demonstrates how gesture and pre-verbal vocal communication, in the context of consistent parental interpretations,

provide the communicative matrix through which children learn to do things withwords (Bruner, 1983). For Stern, further development in putting oneself forward inspeech hinges on a capacity to reverse roles in interaction and to represent the selfor to take the self as an object. This is seen particularly clearly in symbolic play, aschildren begin to represent themselves with dolls and other objects from the end ofthe second year. Stern stresses the gains provided by language, but also the lossof the intimacy provided by pre-verbal communication. As for Lacan, language bringsabout a distancing in interpersonal experience.

It is probably generally accepted in psychoanalysis that language development is

an aspect of separation-individuation, and that there is something crucial about theOedipal situation, or the place of the father. Where a mother apparently anticipatesa babys needs too completely, for example, or where the baby merges with themother to a marked degree, there may be little incentive for the baby to learn totalk. Most would also accept, with Lacan, that the presence of the father may notjust disrupt the exclusivity of the mother-child dyad but also provides another objectfor identication through which self and other can be differentiated. But, as anexplanation for what motivates language development, the emphasis on loss in psycho-analytic accounts smacks of what, in the 1970s, Bruner (personal communication)

used to call get you out of trouble theories of language development, in which theapparently unpleasant process of acquisition is somehow explained by an advanta-geous end product, which the baby cannot know about in advance. For example, acommonly stressed advantage of language is that it allows us to communicate aboutevents which are remote from us in time and space.

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disappear. By crouching down in front of a full-length mirror he discovered that hecould make his mirror image gone, bringing it back by standing up.

We can only speculate on the phantasies and functions behind this game, a versionof Peek-a-boo. These must surely include mastering the anxiety that, in separatingfrom the mother, the baby will lose his self, if he is without the object upon whom

he depends. Another interpretation hinges on the phantasies about what, in herabsence, the mother is engaged in, and with whom; in which case, the mirror gamemight enable the baby to deal with his fear of being displaced. Indeed, it is prob-ably only through discovering or rediscovering ourselves as interesting objects tosomeone, which presupposes being able to identify with a position outside ourselves,that we can deal with the fear of being wiped out entirely.

This child had managed the beginnings of self-representation emphasized by Sternas a prerequisite for the emergence of the verbal self, indicated in his verbal expres-sion, baby oo! But, in this paper, I want to illustrate how it is the presence of a

containing object which makes possible the survival and development of the childssense of self and its verbal evolution. The four children described were all under5 years old at referral. The presenting concerns involved substantially delayed ordisordered language development with accompanying autistic features. These includedavoidance of eye contact, a lack of gesturing, intolerance of change, absence of peerrelations and perseverative rituals. A query about autism was explicit or implicitin each referral. Here I illustrate the disabling impact of deprivation and traumaticexperiences in the parents backgrounds on their ability to provide the kind ofcontaining, interpreting and link-making functions Bions account implies. I alsoillustrate the rather active steps I took to enable the children to reclaim lost or hiddenparts of themselves.

The families were seen in my consulting room, which contains a couch, a dollshouse and two puppets, a dog and a cat. In addition to the usual toy cars, drawingthings, a ball, dolls representing the childs family plus one for myself, domestic andwild animals and bricks, the toys provided included a Galt pop-up peg toy (a woodenbox with four holes with springs at the bottom so that four pegs with faces paintedon them can be made to pop up and down), a yellow car with movable eyes and a

red nipple-like button on the top which makes a noise when pressed, a set of Billy-in-the-Barrel nesting barrels and a pot of bubble mixture.

Four cases

Daniel

The rst child of Scottish parents, Daniel was referred at 3 years simultaneously byhis speech therapist and the special educational needs coordinator (Senco) at his

nursery school. They were concerned about seriously delayed language and autisticfeatures. These included bizarre preoccupations like repetitively opening and shut-ting doors.

I saw Daniel together with our specialist registrar. Though his mother was report-edly very worried, the rst appointment was attended by the father, Daniel and his

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7-month-old baby sister. I became aware of Daniel anxiously hovering at the end ofthe corridor, apping his arms in autistic fashion. A very anxious and obviouslydepressed father explained that the boys mother could not come. She had started anew job as he had lost his own. In the meantime, Daniel had stared very deliber-ately at me and rmly walked off in the wrong direction. Once redirected, he watched

my face furtively for clues, as if he believed he needed to know the way already. Inthe room I noticed that Daniel had brought in a little green wooden engine with athread attached which he pressed against his tummy. He was wearing a green coat.I drew Daniels attention to how Daniels coat and Daniels engine were both green.Daniel smiled at this connection. I began to engage Daniel with the peg toys. Hewas interested. I played Where has it gone? There it is! I put the toy aside, givingDaniel space.

In this intervention I had intuitively recognized that the little train representedan aspect of Daniel. By drawing attention to the similarity between the toy and

his green coat, I underlined a connection with Daniel himself; Daniel felt I noticedhim. This was underlined by the play with the peg toy, a kind of peek-a-boo, whichinterested him because it resonated with his emotional experience of being lost andfound.

Meanwhile, almost in tears, the father wanted to know, Is Daniel ever going totalk? Why is he like this? As far as he was aware, the pregnancy and delivery werenormal. Daniel was a good baby, did not cry much and slept and fed well. Hewalked at about 12 months and from then on was very active. He was also easy totoilet train. However, from about 2 years he had had some food fads. He did notlike different foods to touch each other. For example, sausage should not touch beansor chips. Also, Daniel did not go through a stage of using gestures to ask for orpoint to things. Now, if he wanted things from the fridge, he would go and getthem himself.

This is signicant because pre-verbal communication studies have shown thatnormally childrens rst words used in communication are accompanied by previ-ously established gestural patterns like pointing and reaching in demand (Bateset al., 1975; Bruner, 1983). The absence of these gestures is now used as a diag-

nostic feature for autism in pre-school screening tests (see Baron-Cohen et al., 1992;Lord et al., 1989).As a matter of course, I asked about separations, losses and deaths in the family.

The fathers mother had died close to Daniels second birthday. It emerged that thefood fads came on soon after this. The father became visibly upset talking aboutthis. He was very close to his mother and it was a big shock for the whole family.Daniel also became very anxious at this point, identifying with the fathers distress.Attuned to his anxiety about loss of his self, I picked up the green theme again,connecting Daniels green coat and his green train. To our delight Daniel imitated

green. I drew his attention to the barrels, shaking them and saying, Whats inside?Daniel was able to connect the noise with the idea that there must be somethinginside. After one demonstration, he began to open the rst barrel and then move onto the next. Particularly fortunately, this one happened to be green, which again heimitated. Eventually, Daniel reached the Billy and tried to pull it out.

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The father was amazed and enchanted at Daniels persistence. We never thoughtto teach him his colours, he said, as Daniel enjoyed matching up the colours onthe peg toy and imitating blue and red. Shyly, Daniel showed me the face on oneof the pegs, and then pressed it down. I played, Wheres it gone? There it is!

Shortly afterwards, in a determined fashion, Daniel went to the door. The father

said weakly, Dont go out Daniel. Daniel went out nevertheless. I said, WheresDaniel gone? Where hashe gone? Daniel came in and gave me a stare and a tentativesmile. I said, There he is! Daniel smiled more broadly and went out again. I repeated,Where has Daniel gone? and, There he is! as he returned. Daniel repeated goingout and coming in with great pleasure, registering and representing that now hecould be found and bring himself back.

Greatly heartened, the father was keen to accept another appointment. However,the family failed the next appointment. Fortunately, the third was kept by the mother,Daniel and the baby. We learned that the father was now back at work and was not

able to come. We also learned that Daniel was now talking. He was requesting,imitating and repeating jargon. Particularly important diagnostically, he was alsodrawing attention to things, indicating that he had grasped referential and declara-tive functions of language, despite the early absence of pointing.

This time Daniel had brought his green engine plus another. I learned that thesewere Thomas and his friend. Daniel knew where to come but became anxious,needing to be retrieved from the waiting room. I said perhaps Daniel was lookingfor his father and he was going to the waiting room where he rst met me. Perhapshe was trying to bring us all together. In fact, much of the session was spent inrecapping the previous work, while Daniel periodically opened the door, leaving theroom. I would follow to look for Daniel, saying, Wheres Daniel? to see Danielstanding at the far end of the corridor, where I had rst seen him. Daniel wouldthen grin broadly and run gloriously at full tilt along the entire length of the corridoras if he was playing Wheres Daniel? There he is! in his head. Another repetitivegame was Poor Thomas, dropping the engine on the oor and picking him upagain. At one point he went over to his baby sister, giving her a big hug and sayingPoor baby, turning to smile at us.

The mother conrmed much of the early history and acknowledged how worriedshe had been and that the father had been out of his head with anxiety. We alsolearned that she had an older child by another relationship, who lived with themothers previous partner in Scotland. She was conscious that Daniel had alwaysbeen slower and was not quite like this other child.

We did not hear anything more about the mothers own background and whatwere plainly previous losses. The next session was in fact the last. The mother wassatised with Daniels progress for the time being. They were able to increase specialneeds support in school where he was doing relatively well.

Later we shared our thoughts with the speech therapist. The rapidity of Danielsprogress, his capacity for playfulness, his newly found empathy, the waning of ritu-alistic behaviour and the uses to which he was now putting gesture and language allargued against an autistic spectrum diagnosis. However, Daniel was clearly a veryanxious child, probably constitutionally vulnerable, who had attempted to by-pass

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the normal pre-verbal communication through which the child relies on anothersagency as a source of help. Daniel had apparently opted for a magical or omnipo-tent solution in the search for potency, as described by Alvarez (1992). This involvedidentifying with the father and taking his place so that he would not have to askfor help at a time when his parents distress at the mothers death may have made

it difcult for them to contain the childs anxieties and work together effectively.Daniel had come to the rst appointment as if he had to know the way already.Unfortunately, in this survival strategy the little boy Daniel disappeared. We believedthat the discovery that the little boy Daniel could be recognized and missed underlaythe delight in his running up and down the corridor. Further, losing himself andpicking himself up again may be what he was working through in his persistent playwith dropping and retrieving objects standing for his baby self, Poor Thomas andPoor baby and sometimes Poor Daniel.

Notably, it was difcult to get both parents to come for appointments together.

This has been a feature in all four cases.

Memet

Memet was referred at 3 years 6 months with grossly disordered language develop-ment by the speech therapist from the child development team. Memets otherproblems included developmental delay and clumsiness. The speech therapist thoughtthat the bizarre content of Memets speech suggested autism and/or a thought disorder.It might also have reected events that he had witnessed. Memets mother is Cypriotwith Turkish as a rst language. She came to this country soon after an arrangedmarriage that became violent. The violence continued until the parents separatedwhen Memet was 3 years old. The family did not attend at the time of the rstreferral. Nearly two years later Memet was referred again by his school. By this timehe was an aloof little boy, not relating to other children, though occasionally veryviolent. He was also constantly preoccupied with holding two objects, two cars ortwo action men, trying to force them together.

The mother attended a rst appointment with Memet and also a new Cypriot

husband and a baby daughter, mobile and talking. To my surprise, the husband wastold to stay in the waiting room while Memet somehow ended up leading the waydown the corridor.

Once in the room Memet started to bang the pegs, while his sister pulled thingsoff the table. Confused about what the appointment was for, the mother explainedthat she was concerned that Memet was very slow and had been since birth. Thiswas not planned as she was on the pill. She did not know she was pregnant as shecontinued to have what she took to be menstrual bleeding. She stopped taking thepill in the seventh month. The mother told me reluctantly that her rst husband

had been violent towards her throughout the pregnancy and afterwards. But thenMemet was a baby and, she believed, would therefore not notice. As a baby, Memetwas always slow and a terrible feeder, constantly being sick. He would not take solidsproperly until the fourth year, and even now he was very messy. I have to feed himlike a baby, she said with contempt.



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In the meantime an atmosphere of violence and chaos pervaded the session. Thelittle girl trampled across spilled animals and dolls house furniture while Memet hadtaken charge of the dolls. A father doll was kicking the baby out and stamping onthe mother. It appeared that Memets mother was powerless to stop this aggressiveplay. She wanted me to appreciate her difculties.

I felt obliged to draw a rm line which, interestingly, both the mother and Memetaccepted. That was enough kicking of dolls, I said, and set him to draw a person.Memet drew a boy, a mother, a father and a baby, tadpole like, but appropriatelyordered in terms of size. The mother was encouraged, but laughed at Memets efforts.She wanted me to know how behind he was. With the barrels, at rst, when puttingthem together, he left one out. However, he observed what I did, took them out ofhis sisters way and put them together correctly.

Memet was pleased with his achievement. I suggested to his mother that next timeshe should bring him on his own. She agreed but cancelled the next two appoint-

ments. The Senco was disappointed. I agreed to try again.On reection I felt that the mess and chaos expressed the intolerable anxiety stirred

up by the talk about domestic violence. Perhaps my interest was felt as intrusive. Ialso thought that the mother needed me to see Memet as the source of her prob-lems because of the strength of her persecutory guilt, which she necessarily had toproject. The mothers situation would have made it virtually impossible for her tocontain Memets anxieties as a baby, in the sense described by Bion (1962), whorefers specically to the containment of the infants fear of dying. I suspected thatthis contributed to his subsequent communication difculties. Nevertheless, somesuccess and recovery in the present would be essential before we could begin to thinkabout the past.

We began again with a minimal idea of success. I focused on enabling Memet tond lost objects. I explored what he thought happened to things that were gone,and hoped to establish a context in which things, places and experiences could benamed consistently. On arrival, Memet shrank inside his coat, not sure whether torecognize me in case he was in trouble. However, he went straight for the barrel toyand with some pleasure repeated his previously successful performance. His mothers

main concern remained that he was not learning and that he could not or wouldnot take things in. He still would not go and nd his shoes, even though they werealways in the bedroom. I suggested that the shoes be kept in a special place thatcould be named so that he would know where to look. Memets mother apparentlydid not grasp this; she would tell him and tell him, but he would not look.

I explored Memets ability to look for objects out of sight, using two barrel-halvesto hide a green pencil sharpener, shifting the barrel-halves around. Interestingly, froma Piagetian perspective, he was able to deal with visible displacements, but gaveunusual reasons. He found the sharpener, for example, under the green barrel because

its green or its sharp.I explained to the mother that I was doing this to explore what Memet thinkshappens to things when he does not see them. Do they disappear? Do they changeinto something else? Do they get eaten up or turned into monsters? I was not, ofcourse, aiming to teach Memet object permanence (Piaget, 1936). Rather, I hoped

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to connect with his emotional experience, to build meaning that would enable himto use his intelligence to exploit regularities in his environment. Fortunately, Memetand his mother soon grasped this themselves.

At the next session, Memet greeted me more warmly. He had managed to ndhis shoes this week. His mother had now consistently placed them inside the door

where he could see them. He was pleased. His mother said things were a little better.After enabling Memet to name his clothes and think about the things he puts onin the morning, he asked me to play that game again. By this he meant hiding thesharpener under the barrel shells, extending the hide-and-seek game to include otherobjects. He gave me a boy doll to hide while he worked out whether it was in thishand or in that. When it was not in one hand he would look in the other. Memetwas excited by his success at nding the object. I asked how he knew it was there.Because I am thinking! he said touching his head and grinning. Because I amthinking. Cathy, you are magic!

Memet attributed his pleasure in discovering that he had a mind to me. Sufceit to say, however, Cathy was not magic. His mother told me that the main languagespoken at home was Turkish, but that Memet was now more advanced in Englishand trying to say more. However, in the session he produced some odd verbal asso-ciations. These explained the initial concern about thought disorder and indicatedsomething of his internal chaos.

For example, I used the word, understand. Stand? Memet asked. Stand up?Cant stand? Cant stand it? I referred to Memet having to deal with all thesechanges in his life. Memet started talking poignantly about different sets of clothes.Furthermore, despite the success with nding his shoes, Memets mother had nosuccess in enabling him to get something from the kitchen. Memet would go in toget his cup, stare straight at it and say it was not there. When I asked Memet whatthings are in the kitchen, he said, Batman. Now it is possible that Batman was areasonable answer as some toys were kept in the kitchen. Eventually he was able tosay food in kitchen. A sharp knife. He raised his arms violently, and crashed aboutthe room like a monster before his mother got him to stop. She then talked againabout the terrible early feeding difculties and how even now Memet cannot feed

himself without tipping everything down his front.Subsequent sessions conrmed that Memets difculties with nding thingsreected the persistence of the kind of process Bion (1962) described where theyoung infant experiences the absent object not as something like a good breastmissing but as a highly persecutory present monster. Imagery of sharp knives orvicious teeth, for example, may reect biting pangs of hunger, teething or weaningand/or the young infants attacks on the combined object or parental intercourse.For Memet, the terror arising from the violence of this primitive Oedipal phantasywas exacerbated by the fact that the internal violence was horribly conrmed by the

domestic violence he witnessed.The identication with a violent father, seen particularly in the rst session, allowedMemet to escape the horror of his internal situation, but again at a terrible costto his small boy self. At the same time, Memet was more than usually motivated tokeep things apart, inhibiting things coming together meaningfully in perception and



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more, and trying to co-operate with his brothers and sisters. However, tantrums werestill occurring at school, mostly when he could not have something or somethingwas taken away. Anything gone was gone for good.

As I had not asked before, I asked about bereavements in the family. The paternalgrandmother had died the year before in East Africa, but she had been living with

them before that, very involved with the family. Why did I ask? I explained howchildren react to losses. Shortly afterwards the father arrived, apologizing. The motherbegan a conversation in their language. She told him, she said, what I had said aboutchildren being affected by losses. Tundes father was plainly shocked. He himself didnot think Tunde was affected by the death of the grandmother because he hardlyknew her. But he had been very affected when the family moved house shortly aftershe had left. Tunde had cried and cried at night after that, not wanting to be left.Now Tunde keeps talking about a monster. The father has to go upstairs with him.Monster, Tunde whispered, and leant up against him.

One effect of this intervention was that the family failed the next two appoint-ments. However, I subsequently learned that another was that the father had arrangedfor the mother to return to their country of origin for a holiday in the interim. Shehad not been back since her marriage. When I asked how she got on with her ownfamily, with a wry grin she said, It is a long, long story, indicating a painful anddifcult past.

I never heard the details of this, or of what family members had been visited,or mourning rituals completed. However, the visit clearly had a galvanizing effect.The father had looked after the children when the mother was away. Interestingly,initially Tunde showed no reaction. Then suddenly, in the second week, he askedWhere Mummy?, becoming very distressed, panicking and running a temperature.The family agreed that at rst Tunde did not notice, but then, when he did notice,he got very worried. He had been very clinging and attentive to his mother since.

While grandmothers disappearance may have had more of an effect on Tundethan his parents had thought, Tundes panic states were part of a broader problemin regulating emotional states. Tunde and his mother regularly presented with broadsmiles and apparently buoyant cheerfulness. But Tundes drawings began to indicate

a wider range of facial expressions, culminating in a drawing of Mummy with a verywobbly mouth. I asked what Mummy was feeling. Happy, Tunde said, Mummyhappy, unconcerned but unconvincing. This depiction of a very sad internal objectsupported my sense that Tundes reluctance to feed at night as a baby already repre-sented his sparing a depressed or preoccupied mother. Another consequence of thiswas that he kept parts of himself hidden, as he showed me by secretively coveringup the boy in the barrel,

Quite why became clearer when I began to understand more about the night-timemonsters by seeing Tunde himself in a monster state of mind, when father was away

over two sessions on a training course. At the rst, while I was talking to his mother,Tunde began to overturn the dolls house, bellowing like a bull on a rampage, as ifidentied with a very angry, bellowing parent. This identication was conrmed inthe next session, when his mother told me that the night-time monster had beenaround in earnest. I asked about the bedtime routine. She explained the sleeping



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arrangements. In a two-bedroom at, all the elder children sleep in one bedroom.As the baby, Tunde sleeps with her.

At 4 years of age Tunde was almost certainly caught up in an intense Oedipalsituation. He both wished to usurp his father and was also terried of taking hisplace. In his rages Tunde appeared to be becoming the monster father in intercourse

because of his fear of retaliation. Some conrmation of this kind of process occurredlater in the session. While I was talking to the mother, Tunde became very disturbed,as if the night-time fears were taking over. Tunde stop it, we are going now, themother said. She did not know what made Tunde angry sometimes, as Tunde crashedabout. I commented that Tunde needed help to manage his angry feelings. Tundegot the puppets down, made them ght each other and then gave one to me. Hisfought mine, then he turned them around so that my puppet was to attack his. Icommented on how Tunde was afraid that he would have made me angry and turnedCathy into the big, horrible, cross monster. Tunde was pleased with this, and wanted

me to blow bubbles for him.Despite the intense persecutory phantasies, and possibly facilitating their expres-

sion, there were a number of positive developments going on concurrently. For therst time, Tunde pointed to the white woman doll, called it Cathy, hid it, andplayed my own game back at me. Wheres Cathy? There she is! Tunde thoughtthis was extremely funny. A month later, Tunde gave more evidence of grasping theidea that when people are out of sight they may retain their good qualities. Theparents were pleased to report that when father was away Tunde had told peoplethat he would be coming back at the weekend. Tunde was delighted to see hisfather, giving him glasses of water and asking if he was all right.

Tunde played with the peg toy for the rst time at this session, deliberately makingthe mouths on the faces disappear and showing me this. He also drew attention tothe eyes. Oh dear, boo hoo, pointing to the eyes when he dropped them to showthey were crying because they were dropped, showing a clearer understanding of linksbetween object relations and emotional states.

As for the monster, the parents believed that it had gone for good. In fact itre-emerged in a different form as, in the next session, Tunde produced phantasies

about a new pregnancy, playing out his anxiety as to whether this was something hecould bear. Pushing the yellow bubble car with big eyes slowly and threateninglytowards us, Tunde played that this was a monster baby who could consume every-thing. At home Tunde played at being a monster. His siblings indulged him becausehe is the baby. His mother was not too worried now about Tundes difculties.She believed he would grow out of them. She thought Tunde was as he was becausehe was the last child.

In fact, even without another pregnancy in the family Tunde was moving outpsychologically. He tried to put the Tunde doll into a little drawer in the chest of

drawers in the dolls house. Baby? Oh oh, he shook his head, too big. Tundeunderstood more, asked more questions and wanted to explain more. He would taketurns on the computer, and allow his father to change television channels to watchthe news. Ten months after we began the parents reported that Tunde still neededsomeone to take him upstairs to bed sometimes, but he would now say I dont do

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tempers. Idont do roll-about on the oor. Oh no. Babiesdo that. There was somewish to be more grown up.

At this session, Tunde wanted to blow bubbles. For the rst time he became fasci-nated at looking at his reection. He blinked when the bubble burst. He looked upclose to my eye, I believe at his reection, as if he was not sure whether he would

disappear and be swallowed up by my blink. Tunde could now bear this anxiety,knowing that I was able to retain a memory in my mind that was separable fromthe mirror image of him, and that it would not disappear. But neither this imagenor the memory is the real Tunde. Where is he? Tolerating this uncertainty meanstolerating profound existential anxiety. At this point I think Tundes fascination withthe reection was an outcome of stronger internal cohesion or a more robust object,and that this containment underpinned a stronger sense of self.

FoyzalDealing with mirrors was also problematic for the fourth child, Foyzal. At 4 years,Foyzal presented as electively mute at school. He was referred for additional concernsabout autism. He has learning difculties, as does his father, who speaks English andcame to this country from the Indian sub-continent when he was 10 years old. Hismother does not speak English. Foyzal has two younger brothers, developing normally.I saw this family with a male interpreter. In this case a major aspect of the workinvolved releasing the inhibition contributing to the elective mutism. This becamepossible after enabling the parents to see their achievements in a positive light andto talk through their traumatic experiences.

At their rst appointment, unlike the other three children I have described, Foyzalmade no assumptions about knowing the way, but padded along beside me like anovergrown baby. In the room he went immediately for the car with eyes and pressedthe red button to try to make them disappear. He gave the impression of wantingus to disappear as well.

The parents concern was that he did not speak at school, though he spoke athome. For example, he would say what he ate for dinner at school. He now ate rice

and other things, but as a baby he had been very difcult to feed. The father gloomilysaid that Foyzal was the same as him. He had been to a special school. It had notdone him any good. I said that it was very good that Foyzal was now eating solidfoods. At this positive comment, Foyzal came to the table and obligingly gentlyremoved the crocodile from the animal box.

Shortly afterwards Foyzal found the barrel toy. He watched me begin to open it,rapidly got the idea, and smiled appreciatively at the end when I emphasized, Itsa boy! He tended to leave out a cup when putting it back together again, butpersisted until he got it right. However he walked off limply when little brother

muscled in.I attracted Foyzals attention with a doll and asked him to put the doll in thedolls house, pointing. He did this. I asked him to give the doll a bath and then toput the doll to bed. He did this appropriately. His mother insisted that he under-stood things perfectly. But she was plainly very pleased to have this demonstration.



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The family was keen to come again but in the event failed the next two appoint-ments, the father coming alone with Foyzal for the one after that, apologizing gloomily.Foyzal looked at me directly, disarmingly silent. However, he was keen to get thebarrel toy open and pulled hard at the Billy inside. My intuition was that this wasan expression of castration anxiety, related to observing me talking to his father. I

attempted to interest him in the peg toy, but he turned the faces away. He beganto draw long shapes like caterpillars.

Meanwhile the father complained again that he and Foyzal were just the same. Iwondered if he thought that Foyzal had the same reasons for not talking as he mighthave had. The father brightened and said he thought it might be for different reasons.Perhaps Foyzal is shy.

I recalled that Foyzal had been very difcult to feed as a baby. Foyzal had beenborn in their country of origin, the father explained. He himself was not able to bethere. It was some time before he could get his wife over to the United Kingdom.

His wifes mother had died soon after Foyzal was born. His wife had had no parentsto support her. But he had to come back to be in this country with his own family.

At this point Foyzal silently interrupted me to show me that there were ies onthe front of the Billy in the barrels trousers. I said this was very denitely a boy!

Foyzals coming forward in this way was, I think, closely connected to his fatherstelling his story and feeling strengthened by it. The father told us that he sometimestakes Foyzal to the local airport to watch the planes, which he loved, although hehad not been on a plane since he was very small. I drew a plane, Foyzal added someappendages, then covered them up.

At the end of the session I showed Foyzal the bubbles. He was interested butcould not or would not blow, shrinking away. Like Tunde he became alarmed whenhe saw his own reection in the bubbles, and when he saw me looking at him inthe mirror. I wondered silently whether Foyzal was alarmed at seeing two of me, orme in the wrong place, or whether he was afraid I would get right inside him anddevour him with my eyes. While I was thinking this, he went to the animal boxand took out the crocodile and the lion, feeling their teeth. As I commented to thefather how much Foyzal understood, and how much he was trying to communicate,

Foyzal picked up the mother pig and a baby pig, and had the mother feed the baby.This conrmation that I understood Foyzals emotional experience was very moving.Unsurprisingly, Foyzal found it hard to separate at the end of the session. I said thatFoyzal was angry at having to go, but we would play with these things again nexttime. Foyzal watched my face and touched his own teeth.

This was the rst direct indication that inhibition of aggression was affecting whatFoyzal allowed in and out of his mouth. At the next session he was much occupiedwith watching my face, drawing faces with mouths with teeth, which he did notscrub out afterwards.

More substantial changes in expressed emotion came after the next session, attendedby both parents. Through the interpreter I asked the mother more about the earlyhistory. The mother had been living with her mother and sisters when she was preg-nant. Her mother became seriously ill unexpectedly. It was a big shock when shedied soon after Foyzals birth. The labour was straightforward and he was a good

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weight. But he would not feed from the breast. The mother started crying. Foyzallooked up sharply, alarmed, watching her face.

After this I engaged Foyzals attention with the peg toy. He looked at the littlefaces, and followed my lining them up until his little brother intervened. Foyzalsurreptitiously took animals and dolls to the dolls house. The crocodile savagely

attacked and fought the baby.This play suggested the degree to which rivalry with his baby brothers, and anxiety

about the consequences of his aggression, may have been inhibiting him. But it isalso possible that Foyzal was already inhibited within the early feeding relationship,like Tunde, dealing with the internal world of a depressed and preoccupied mother.

The mother attended the next appointment with Foyzal and a younger brother,without the father. The mother complained that Foyzal was the same but it soonemerged that by the same she meant that Foyzal was becoming more difcult. Inthe session, one of the most striking changes was in the exuberance of the play

between the two boys. Now Foyzal would not give way when his brother took thingsfrom him. There was a good deal of more or less playful ghting between them andbetween the dolls, some of it plainly mirroring sexual intercourse.

At the end of the session Foyzal requested the bubbles, which he now enjoyedthough he could not blow them. Before nishing, the mother asked if I could helpwith their housing situation. We learned that all ve of them were living in oneroom in her father-in-laws house, inhabited by other members of the extended family.Embarrassed, she said that her husband was reluctant to move because he did notwant to leave his family.

I was shocked by the overcrowding. I wondered if they could move to anotherat somewhere nearby. I said I would write a letter, adding that, from the play, shehad two growing boys here and they were getting too big to be in the same roomas their parents. The interpreter looked extremely worried at the task of interpretingthis but said he would do his best. An animated conversation ensued, into which Iwas eventually included. The interpreter explained that he had said what I said in apolite way. The mother had said she knew exactly what I meant and she quiteagreed. Please would I have a go telling her husband!

At this point I felt a sharp pull on my arm. Foyzal had got hold of the bubblesand had pulled the lid off. Phew! Phew Phew! No longer afraid, Foyzal was blowingglorious strings of bubbles across the room. At the door Foyzal wanted to give mea kiss. Bye bye, he said, Bye, bye, bye.

There are many reasons why this was a pivotal moment for Foyzal. The adultstook responsibility for saying something unsayable, referring to the parents sexualrelationship and the fathers separation difculties. The work done by the interpreterwas considerable. He was broaching a cultural divide that interestingly mirroredFoyzals elective mutism. Foyzal was avoiding going public in the language of the

dominant culture outside the home, spoken by the father but not the mother.Over the following weeks the changes in Foyzal were neither rapid nor dramatic. Hecontinued to say Bye at the end of sessions, to become more outgoing and to enjoy thebubbles. He also enjoyed looking at himself in the mirror. The father did agree to applyto the housing department, in the meantime getting bunk beds for the two elder boys.



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For various reasons, after the family had been attending for about six months, wedecided to have a break in the work and to review again in six months time. Thereview was held early in 2000 and attended by Foyzal and his father. Foyzal wrotethe date and the year, 2000. I wondered if he had seen the reworks celebratingthe Millennium. He nodded, and began a funny little drawing like an upturned

spider with spiders legs. I turned to talk to the father. They were quite pleased withFoyzal. He was working hard and doing homework. Foyzal interrupted, to producehis rst statement in a session, I have seen the Millennium Dome! We went on theDocklands Railway. Then followed a quiet but articulate discussion of the millen-nium celebrations. With encouragement he drew a picture of the Docklands trainwith passengers and a driver. Though immature, this was a substantial advance overprevious drawings.

I saw Foyzal for review subsequently. At that time he was a good looking,caring boy with very powerful eyes and a passionate relationship with his mother.

He remained a quiet boy at school, but was no longer isolated and activelyrelated to peers. Particularly encouraging, there had been some changes in measuredintelligence.

Discussion

At the beginning of this paper I described some different approaches to languagedevelopment within psychoanalysis and developmental psychology. Each offerscomplementary explanations of language delay, focusing on different aspects of theacquisition process.

I began with Lacan, whose views on language were inuenced by the work of deSaussure, a linguist whose major contribution was to argue for the notion of signif-icant difference as the basis of meaning in language. To understand how, for example,the word tree comes to signify vegetation with a trunk, branches and leaves, onehas to understand the relation between this word and other words in the languagewhich denote things that a tree is not.

Though the link between words and things is arbitrary, something must ensure

some relative stability. Lacans originality lay in relating the acquisition of languageto the growth of the psyche as described in psychoanalysis such that the growth oflanguage is part of the growth of mind, with culture implicated within it.

For Lacan it is through what he calls the Law of the Father, prohibiting thechilds access to the mother through the universal incest taboo, that the position ofthe phallus gains centrality in the relative xedness of the meanings in a language.Thus the difference that makes the difference in language is underpinned by thecastration complex and the Oedipal situation. As Lacan puts it, sooner or laterwe all have to decide whether to line up with the ladies or the gentlemen (Lacan,

1966). This emphasis also means that language is necessarily gendered, and languagedelay or disorder may reect difculties in negotiating the Oedipal situation orits precursors.

More recently, developmental psychology has understood the problem of whatunites words and things in terms of the problem of reference, or what allows speaker

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and hearer to identify for each other the same object or event in the world, real orimagined. The roots of this are now thought to be pre-verbal. Thus, the kind ofturn-taking games and reciprocal interactions described by Bruner (1983), Stern(1985) and others for ensuring the mutual regulation of attention and intentionunderlie the primacy of pragmatics in language, that is, devices for interlacing perspec-

tives between speaker and hearer. They are also thought to pave the way for referentialcommunication. Particular attention has been given to communicative pointing, asindicating the skills involved in drawing anothers attention to a particular object inthe world (Bruner, 1983). Hobson (1993) has seen the clinical signicance of thisin his work on understanding autistic children. For them the difculty with, orabsence of, communicative pointing is but one aspect of a more global problem inidentifying with another persons point of view. Insofar as this requires being ableto represent the position of the other, this position is broadly compatible with thatof Stern (1985), for whom the representation of the selfother relation is integral to

the emergence of the verbal self.Another set of possibilities, however, follows from the work of Bion, for whom

language development begins at a more primitive level concerned with the commu-nication of emotional experience. For Bion, what connects signs and their referentsor signicates depends ultimately on a relation with a thing in itself, which, followingKant, is essentially unknowable. However, it also depends crucially on the develop-ment of what he calls alpha function, the capacity to sustain thinking about emotionalexperience. This carries with it its own momentum, as a link-making, self-generatingprocess.

Like Lacan and the developmental psychologists, Bion would need to account forhow or why children are eventually motivated to adhere to the particular languagesystem used around them. For Bion, this socialization would be underpinned bythe move into the depressive position, and with it the pre-genital Oedipal situation.As this is a psychoanalytic account, this entails coming to terms with separation andloss. However, in the depressive position or the pre-genital Oedipal situation, thepressure of internal reality creates the phantasy of displacement that makes commu-nicative effectiveness in the outside world highly desirable. As Burhouse (2001) has

argued, it is likely that the growth of deliberate pointing in the outside world islinked to this internal shift. Put simply, ordinarily babies use of language to gainand direct attention to themselves and the world means they are less likely to feelleft out.

Moreover, from the argument developed here, it is not just the signicance of lossinherent in the depressive position that drives language development, but its gener-ativity, the unstoppable coming together of things in new relationships. Thoughdesigned for another purpose, Bions diagram (Figure 1) illustrates how the obser-vation of many examples of symbolic relations may create a pressure on the psyche

to create new structures to encompass developing concepts, although what ultimatelylinks them may be unknowable. Here, for example, Daniels discovery that the wordgreen could link his coat, his train and himself led on to his need for more wordsto name other colours, as he grasped the relation between colour as a concept andwords in the language.



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For Bion, where there have been repeated impediments in the communication andmodication of emotional experience, the development of a link-making functionwill be impaired. Implicated in the breastmouth link initially, this will eventuallymanifest itself in the link between the parental couple on which, symbolically, thegenerativity of the depressive position is based.

Where would one place the children described in this paper? Though there aremany differences between them, the four children are all developing against a back-ground of deprivation and trauma in families dislocated from their countries of origin.In consequence, as is common in families where there are children with communi-cation difculties, more work than usual was necessary in liaising with external agenciesand in enabling the families to attend. It was often hard for both parents to attendthe appointments simultaneously. I have suggested how the parents own tragedieshad impeded their ability to contain their childrens anxieties, cutting across linkmaking and contributing, quite literally, to a nameless dread as described by Bion,manifested in delayed or inhibited use of speech. All the children showed distur-bances in feeding and anxiety about taking in through the mouth. This anxiety may

have had implications for early symbol formation, at the level described in the conceptof the theatre of the mouth, which Meltzer (1986) derived from Bions notion ofcreative links between mouth, nipple and breast. However, it is also clear that, inthe case of at least three of the children, their anxiety and inhibition was exacerbatedby an infantile view of parental intercourse as violent and terrifying. Containingthe anxiety associated with these universal phantasies is especially difcult for youngchildren frequently caught up in domestic violence. It is also particularly difcult incases where constitutionally vulnerable children have repeatedly been witness to sexualintercourse. In both situations the external reality then matches the internal situa-

tion too closely. Rather than reaching the generativity of the depressive position, achild locked in this kind of internal scenario, inside the primal scene, may be drivento break links, to keep things apart. Here, the consequences included disorderedthought, a retreat into mindlessness and an identication with violent internal gures,as well as delays in language development.

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Music Religion Sculpture Poetry Painting

Instrument God Stone Language Paint

Root

O

Source: Bion (1992: 323)

Figure 1


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Enabling the parents to begin to talk about their own situations contributed totheir capacity to respond to their children as children, and to the withdrawal of someof their own projections. But I have also highlighted the active steps I took to reclaimand bring forward hidden parts of each child, after rst identifying and modifyingin the countertransference the nature of the object with which he was partially iden-

tied, whether absent, dead, collapsed or highly persecutory. For each child it was abig step when he could show that he knew that I knew that there was a little boyinside the barrel, and that it was a pleasure to bring him out. This coincided withdeveloping a sense of the generations, a clearer gender identity, a capacity to uselanguage with a new authenticity and a waning of autistic features.

The interventions lasted from four months to one year. At the end, all the chil-dren still have special educational needs, and two have full Statements of SpecialEducational Needs. This entitles them to gain extra help in school. Nevertheless, therelatively brief and non-intensive work led to a substantial waning or disappearance

of autistic features. Did the work stave something off, cure something or was theconcern about autism inappropriate?

This work did not cure autism. The initial concern, though, was completely appro-priate. The interventions had a huge impact in mobilizing the potential in the childrenand parents, opening new developmental pathways. The increasing incidence of chil-dren being given a psychiatric diagnosis of autism or autistic spectrum disorderencompasses a wide range of different presentations and degrees of severity. Psychiatricdiagnosis does not necessarily correspond with what we may think of as signicantpsychodynamically. Psychiatric diagnosis depends largely on the presence or absenceof dening characteristics. This can mask signicant differences between children andfail to do justice to their developmental strengths.

A psychodynamic viewpoint can complement psychiatric diagnosis by describingthe nature of the childs object or part-object relations that contribute to the symp-tomatology, the ego decits and their implications. It may also be able to describethe personality characteristics of children who overcome some of their difculties asopposed to those who do not. Psychotherapy with autistic children has now givenus considerable insight into the phenomenology of autism, providing valuable descrip-

tions of different kinds of internal situations contributing to different presentations.These include Tustins (1981) original distinction between encapsulated autism andschizophrenic type autism, where the object is more persecutory and fragmenting,and Alvarezs (1999) more recent distinction between undrawn as opposed to with-drawn autistic children, with the emphasis on the nature of the decit in the objectscontaining capacity and the childs response to it. Most of this work has dependedcrucially on Meltzer and his colleagues careful analyses and descriptions of howfundamental problems of containment impact on the development of mental space,contributing to the two dimensionality and stuck-on quality of autistic childrens

thinking and relating (Meltzer et al., 1975).From this point of view, what was striking about these children was that theyactively sought containment, and were not overly dominated by two-dimensionalthinking. They were positively interested in what was inside the barrels. Moreover, withthe possible exception of Tunde, none of them dismantled the sensori-perceptual



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apparatus under the pressure of emotional experience, as described by Meltzer (1975).In consequence they seldom showed evidence of going into autistic states of mindproper. Rather, these children were getting by on hugely omnipotent solutions.Apparently in mammoth projective identication with variously depressed, ineffectualor aggressive fathers, these solutions reected a search for potency, in the sense

described by Alvarez, as the children made the best of their psychically deprived cir-cumstances. As Maria Rhode (personal communication) has suggested, this impliesthat they had managed something of the developmental shift from mother to father.This itself argues for some three dimensionality and is in contrast to children whoidentify more or less completely with a collapsed or highly damaged primary object.

In my view, this factor, along with the availability of alpha function, differenti-ates these children from children who are clearly autistic. However, there are someinteresting similarities between these children and accounts of children in the liter-ature for whom a diagnosis of autism is unequivocal. This gives this work general

relevance. For example, Rhodes (1999) recent work on language development inautistic children describes how she has come to focus on enabling the child to ndhis or her authentic voice. This depends on the child becoming reunited with hiddenparts of the self, possible only once the tolerance of emotional experience has increased.Similarly, it is also striking how often, within the collection of papers edited byAlvarez and Reid (1999), Peek-a-boo emerges as the children begin to recover. Thisis illustrated in Reids (1999) vivid account of an assessment in which, after anunpromising beginning, a little girl becomes able to represent her self and to playPeek-a-boo, making herself appear and disappear. Reid describes how cheered shewas by this. I would go so far as to say that Peek-a-boo is a hallmark of the emer-gence of the non-autistic personality, and it is to support such a process that theI-me-you-it games of infancy are so important, and a justied aspect of psychother-apeutic technique.

Flat 118 Alexandra Grove

London N4 2LF, UK

e-mail: [email protected]

Acknowledgement

I should particularly like to thank Linda Dawson, Andy Cohen and Nural Huquefor their invaluable help in this work and in writing this paper.

References

ALVAREZ, A. (1992) Live Company: Psychoanalytic Psychotherapy with Autistic, Borderline,Deprived and Abused Children. London: Routledge.

ALVAREZ, A. (1999) Addressing the decit: developmentally informed psychotherapy withpassive, undrawn children. In ALVAREZ, A. and REID, S. (eds) Autism and Personality.London: Routledge.

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ALVAREZ, A. and REID, S. (eds) (1999) Autism and Personality. London: Routledge.BARON-COHEN, S., ALLEN, J. and GILLBERG, C. (1992) Can autism be detected at 18

months? The needle, the haystack and the CHAT. British Journal of Psychiatry, 161:83943

BATES, E., CAMIONI, L. and VOLTERRA, V. (1975) The acquisition of performatives priorto speech. Merrill Palmer Quarterly, 21: 20526.

BION, W. (1962) Learning from Experience. London: Heinemann.BION, W. (1967) Second Thoughts. London: Heinemann.BION, W. (1970) Attention and Interpretation. London: Heinemann.BION, W. (1992) Cogitations. London: Heinemann.BRUNER, J.S. (1983) Childs Talk: Learning to Use Language. New York: Norton.BURHOUSE, A. (2001) Now we are two, going on three. International Journal of Infant

Observation, 4(2): 5167.FREUD, S. (1920) Beyond the Pleasure Principle. SE 18: 164.HOBSON, P. (1993) Autism and the Development of Mind. Hove: Lawrence Erlbaum Associates.

LACAN, J. (1966) Ecrits. Paris: Seuil; trans. A. Sheridan, London: Tavistock, 1977.LORD, C., RUTTER, M., GOODE, S., HEEMSBEREN, J., JORDON, H. and MAWMOOD,

L. (1989) Autism Diagnostic Interview Schedule: standardised observation of commu-nication disorders. Journal of Autism and Communication Disorders, 19: 185212

MELTZER, D. (1975) Autistic states and post autistic mentality. In MELTZER, D., BREMNER,J., HOXTER, S., WEDDELL, D. and WITTENBERG, I. Explorations in Autism: APsychoanalytic Study. Strath Tay, Perthshire: Clunie Press.

MELTZER, D. (1986) Studies in Extended Metapsychology. Strath Tay, Perthshire: Clunie Press.MELTZER, D., BREMNER, J., HOXTER, S., WEDDELL, D. and WITTENBERG, I. (1975)

Explorations in Autism: A Psychoanalytic Study. Strath Tay, Perthshire: Clunie Press.PIAGET, J. (1936) The Origins of Intelligence in the Child. London: Routledge & Kegan Paul.REID, S. (1999) Assessment of children with autism: a family perspective. In ALVAREZ,

A. and REID, S. (eds) Autism and Personality: Findings from the Tavistock Autism Workshop.London: Routledge.

RHODE, M. (1999) Echo or answer? The move towards ordinary speech in three childrenwith autistic spectrum disorder. In ALVAREZ, A. and REID, S. (eds) Autism andPersonality: Findings from the Tavistock Autism Workshop. London: Routledge.

STERN, D. (1985) The Interpersonal World of the Infant. New York: Basic Books.TUSTIN, F. (1981) Autistic States in Children. London: Routledge & Kegan Paul.

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