Prologue: The Interpersonal World of the Autistic Infant: An Interdisciplinary View

In 2012, the Journal of the Nervous and Mental Disease published a posthumous interview with Daniel Stern who was asked about the relevance of developmental research to clinical theory. He brought up the case of autism:

I think that you could have a whole specialty concerned

with autism because it is the quintessential disease of all psychiatry.

It is the disease around which, if we never understand it, we’ll never

deeply understand much about psychiatry. It’s the human enigma

disease and gives force to the new studies of intersubjectivity.

(Talbott & Stern, 2012)

Like his contemporary, Colwyn Trevarthen (a contributor to this issue), Daniel Stern had long sought to plumb the mystery of human sociality. What made it possible for a neonate to organize its bodily intentions in such a way that they could be discerned as meaningful to others? What sort of innate capacities permitted the infant to grasp their caregiver’s gestures and vocalizations as “holistic happenings” rather than a “blooming buzzing confusion”? In current parlance, each attended to a different ‘enactive’¹ (Varela et al., 1991) – pre-reflective, embodied – aspect of how infants made sense of their interpersonal world. Stern found a way to language the ‘silent world of movement’ (Sheets-Johnstone, 2000) into a comprehensive picture of embodied social perception. He showed that dyadic experience-sharing – our ability to affect and be affected by another – is underpinned by the mutual legibility of each partner’s expressive forms of dynamic vitality. In order to ‘read’ the nuances of others’ feeling states – and coordinate aims and intentions – we need to parse and resonate with the temporal-kinetic dynamic contours of their facial and bodily expressions. Trevarthen has brought attention to the innate response-seeking personhood of the infant (cf. Lichtenberg’s “the do-er doing”) demonstrating that infants come into the world with a “delicate and immediate awareness” of others and a “prospective” sensory-motor intelligence that is alive to the imaginative possibilities of interaction. Taken together, their work highlights the primacy of movement in development and opens a window into the moment-to-moment, implicit dynamics of intersubjective engagement and the therapeutic process that has been broadly assimilated into clinical work.

Though it had long been known that autistic people move differently and experience a range of atypical sensory-motor challenges – including difficulty with holistic perception and interpersonal coordination – sensory-motor deficits have long been considered mere associated features – of little or unknown pathogenetic significance. There has been no comparable paradigm shift – as in psychoanalysis – to an implicit psychology of autism.

This issue began with a thought experiment: what would Daniel Stern – who did so much to draw awareness to the role of intersubjectivity and forms of dynamic vitality in typical development – have made of the current state of autism research? Are we any closer to grasping the interpersonal world of the autistic infant?

Research now shows that signs of autism can be detected earlier than previously thought, through retrospective micro-analysis of early dyadic interactions and that disturbances in embodiment including impairment in prospective movement and the perception of dynamic vitality forms are present not only in children with ASD, but persist throughout the lifespan, with pronounced effects on adaptive functioning – even among “high-functioning” autistics. Along with this new appreciation for the implicit early dimension of autistic development, now vividly depicted in a burgeoning first-person literature by autistic adults (Donnellan et al., 2013), the field of autism has attracted the interest of phenomenological philosophers, neuroscientists, and developmental psychologists keen to re-conceptualize ASDs in enactive, embodied terms. One interesting consequence of this interactive turn has been the revival of interest in microanalytic research on dyadic interaction – and a new willingness to consider its relevance to autistic development and treatment (Gutstein & Sheely, 2002; Pickles et al., 2016).

And yet, despite the explosion of research since his death, Stern’s hope for a foundational integration of psychiatry – a reckoning between “the new studies of intersubjectivity” and the nature of autism – remains incomplete. Though we’ve moved past the notion of “primary autism” and the “refrigerator mother,” psychoanalysis’ place within the autism field remains somewhat vexed. There is still little consensus as to what – to paraphrase Stern – a clinically relevant autistic baby might look like. Analysts acknowledge the importance of neurology and increasingly refer to disruption in intersubjective engagement in their clinical work (Emanuel, 2014; Topel & Lachmann, 2008) but few models draw on empirical microanalytic research, or account for the nature and relevance of embodiment – and especially sensory-motor – deficits in early autistic development.

As many of the contributors to this issue point out, it is not for lack of evidence. In Kanner’s original case report itself, we find this observation of a “highly significant” finding: “almost all out mothers recalled their astonishment at the children’s failure to assume at any time an anticipatory posture preparatory to being picked up … ” (italics in the original). A consummate descriptivist in the Meyerian vein, Kanner lacked a psychobiological theory of development in which to ground his meticulous observations and so was unable to explain what, if any, relevance this evident impairment in the sensory-motor domain might have for these childrens’ difficulty making “affective contact” with their caregivers. Then again he composed his case report at a time before the biological turn in psychiatry, before Bowlby introduced attachment theory, when the study of emotions and intersubjectivity still lacked the imprimatur of rigorous, empirical science. Child psychiatry was itself in its infancy, and still under the sway of Freud’s topographical model, a one-person psychology that denied primary intersubjectivity altogether. In other words, the infant was not considered to be experience-expectant in a relational sense. She was not homo provocans (Nagy & Molnar, 2004), not “wired to be social” (Castiello et al., 2010). Absent a coherent neurodevelopmental framework of what was different about autistic children the blame for autistic behaviors came to rest squarely with the environment, i.e., parents. Hence, the notorious refrigerator mother hypothesis which did much to discredit psychoanalytic and psychotherapeutic approaches generally, sidelining them for a generation. After Kanner, ASD research on social cognition was dominated by cognitivist models of the mind and rarely considered movement dynamics per se, despite its growing prominence in the neurosciences (e.g., discovery of mirror neurons) and despite findings that motor function and motor cognition – e.g., capacity to mimic, spontaneously imitate – is reliably impaired in children with ASD (Hobson & Lee, 1999). Movement was considered at best an artifact of measurement – as something to “control for” as if how we move were independent of how we perceive, feel or relate. Likewise, perhaps because of the notorious parent-blaming during psychoanalysis’ heyday, researchers and clinicians alike have been wary of emphasizing the interactional/relational aspects of autism’s pathogenesis as if this would open the door to another generation of parental stigmatization. As a result, autism research has remained hermetically sealed from the wider study of typical development. Important attempts to integrate the sensory-motor domain into clinical treatment have been made (e.g., Greenspan’s ego-psychological Floortime/DIR approach) but there remain few synthetic models of autism that connect its psychobiological origins in perinatal development with its later manifestation as a disruption to agency, intersubjective engagement and atypical social cognition.

To address this conceptual gap, I invited an interdisciplinary array of experts, all of whom operate at the boundary of phenomenology, empirical infant-mother research, and psychoanalysis to explore the very concerns that preoccupied Stern in light of recent research into autism: How do infants later diagnosed with autism come to participate in the “dance of relationship” with their caregivers? What is the nature of sensory-motor impairment in autism and how does it affect the development of interpersonal and intrapersonal self-experience?

This issue – the first of two focusing on the interpersonal world in autism – includes five articles beginning with an overview and explication of research into the earliest period of autistic development, a view of “the music and dance” of therapeutic process in the psychoanalytic treatment of autistic children; and finally, three articles exploring models of autistic embodiment that integrate the sensory-motor and psychological realms of subjective experience.

By no means is this collection meant to present a comprehensive theory of autism etiology or treatment or to diminish the importance of more traditional verbally-based therapies. Rather, by bringing overdue attention to the implicit, experience-near dimension of autistic development, the aim is to generate creative dialogue around “the human enigma” condition between psychoanalysis and a wider array of adjacent disciplines.

The first article, by Filippo Muratori and Fabio Apicella, begins with a fascinating historical account about an overlooked pioneer in the field, psychiatrist George Frankl, who presciently grasped the disconnection between affective and verbal language in autism. We are led to wonder: What would the history of autism had looked like had Frankl – and not Kanner – shaped the discourse around autism? Drawing on their own widely cited retrospective micro-analytic research into the nature of sensory-movement deficits in infants later diagnosed with autism, the authors go onto describe how “fluctuating” deficits in “motricity” – and not a lack of “social motivation” – affects these infants’ capacity to provoke and sustain interactions with their caregivers. Like Frankl – and other contributors to this issue – Muratori and Apicella suggest that autistic people “only appear socially uninterested” and that we have historically misconstrued autistic communication as aimless when it is in fact constrained by a cumbersome sensory-motor apparatus.

In the second article, Alexandra Murray Harrison highlights an important dimension of embodiment and relationality not addressed elsewhere in the issue, using micro-analytic case descriptions to demonstrate the value of polyvagal theory as a framework for providing “safety and comfort” in the treatment of autism. In this view, the polyvagal “neuro-motor system” mediates between the autonomic nervous system and the social engagement system, and “allows humans to communicate (and apprehend) physiological states – i.e. to distinguish between a person who is calm and safe from a person who is agitated and unsafe – via neuroception of their facial expression and vocal intonation (prosody).” She proposes that neurodevelopmental deficits in autistic individuals can interfere with the experience of safety and illustrates how attending to the “music and dance” of therapeutic process can improve intersubjective engagement in the dyadic treatment of autistic children.

In the third article, Magali Rochat and Vittorio Gallese lay out a comprehensive and detailed review of studies that demonstrate the cascading effect of early disruption in sensory-motor function and non-verbal communication on early development. Building on this evidence they offer an expansive treatment of the role of dynamic forms of vitality in both typical and autistic development, tracing the concept from Stern’s original formulation to its more recent incarnation as a key neurophysiological substrate for “pre-reflexive embodied intentionality.” Autism, in their view, is marked not only by impairment in mirror neuron function (embodied simulation) but also by disruption to the expression and perception of forms of dynamic vitality. In support of this hypothesis, they review cutting-edge research into the brain-basis of vitality form (VF) processing, positing, “a mirror insular-cortical network specific to the VFs and acting in parallel with the classic parieto-frontal mirror circuit, [that] would integrate and translate the visual, acoustic and interoceptive information into a motor format, allowing both the expression of an affective inner state and the understanding of others’ dispositions.”

The fourth article is the fruit of a unique collaboration between Jonathan Delafield-Butt, Colwyn Trevarthen, and an autistic adult, artist, and researcher, Penelope Dunbar (Pum), and offers a remarkable synthesis of developmental theory, affective neuroscience, and psychoanalysis. Building on the work of Panksepp and their own previous work on the psychobiological origins of autism, the authors outline an integrative brain-body conceptualization of the embodied “Core Self” and its relevance for autism pathogenesis and treatment. In this view, “The Core Self is non-verbal, expressive in the language of body movement, gesture, and intonation of the voice” whereas the “higher-order Self is developed socially with others, and is therefore structured and organized by conventional social expectations.” Turning to Pum’s development, they note that due to autistic disruption in the intra-personal integration of her Core Self, she “learned language rationally, ‘outside’ of her body.” Applying a Winnicottian perspective they propose that like many autistic adults, “this dissociation between her rational center of control and her intuitive motive impulses dependent in-the-moment on affective and sensory-motor evaluations for action, developed into … a ‘False Self.’” In the final section, they argue that “in order for the True Self to develop, the environment must be adapting to support the individual with autism’s need to be met” and evocatively describe how Pum’s practice of swimming and collage-making – which both involve “embodied self-reflexivity in changing sensorimotor movements” – helped restore coherence to her Core Self and a harmonization between her intrapersonal and interpersonal worlds.

Finally, Shaun Gallagher, Laura Sparaci, and Somogy Varga explore a synthetic model of social cognition in autism from an enactivist philosophical perspective. Drawing on performance studies and dynamic systems models of “coordination dynamics,” the authors develop an alternative to individualistic, cognitivist theories of social cognition. In their view, social cognition can be considered “as a form of embodied-situated performance.” They conclude by elaborating on the implications of such a model for our understanding of ASD where “the integrative meshing of what we called the whole dynamical gestalt of intersubjective interaction seems to be differently aligned.”

Daniel S. Posner, M.D.

Issue Editor

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No potential conflict of interest was reported by the author.

Additional information

Notes on contributors

Daniel S. Posner

Daniel S. Posner, M.D., is assistant clinical professor of psychiatry in the Icahn School of Medicine at Mount Sinai Hospital System in New York City where he teaches and supervises residents in psychodynamic psychotherapy. He has published in the Journal of Autism and Developmental Disorders and is a member of the editorial board of Psychoanalytic Inquiry. He maintains a private practice in Manhattan.

Notes

¹ From an enactive perspective, actions and movements play a fundamental role in the sense-making activity of individuals: It is through our movements that we enact a world of meaning and maintain a sense of self.