Written by Richard Solomon, MD

 

“It is play that facilitates growth and therefore health.”  —D.W. Winnicott

Recently I’ve been reading DW Winnicott, the revered British child psychiatrist who explained why children carry around and are so attached to their ‘blankies’, their security blankets, like the one Linus carries around in the cartoon series Charlie Brown. What Winnicott says is that the newborn baby at the breast is bonded to the mother—IF the mother is ‘good enough’ at nurturing—in a way that merges the baby and mother. The baby is not aware of any separation. Soon, however, by the 3rd to 4th month of life, the infant begins, just begins, to sense that the mother is separate. When the first teeth come and the baby bites the mother’s nipple and mother pulls away and says “No, no, no, baby, that hurts.”, the 6-month-old starts to experience the mother as separate.  In other words, the baby now experiences his or her own subjectivity, a sense of self, separate from the mother, for the very first time.

In a typical child, this sense of separation grows toward full individuation around age 3; three-year-olds are fairly independent little beings. Stranger anxiety, the sense that I am separate, and I don’t know you, emerges by 9-12 months. When I was a general pediatrician and I had a 15 month old in for a well child check I wouldn’t even look at the child knowing that as soon as I did they would panic and start crying for their mother, thus ruining any chance of listening to their thumping little hearts and their screaming lungs. Their awareness of danger was so acute. This sense of separation from the mother and the associated anxiety creates a feeling of insecurity. Enter the blanket, the thumb, the carried object. Winnicott calls these objects, ‘transitional objects’ and the process of becoming separate the ‘transitional process’.

The question I want to explore in this blog is “What does this ‘transitional process’ mean for children with autism and what does it have to teach us about all of our children (and ourselves!)?”

So, in typical children there is a 3-part reality—inside me, outside me, and the space between—this 3rd space—where the ‘blankie’ comes in. But what if the child has autism? Is there then a 3rd space? My observations, over the last 25 years of caring for thousands of children with autism and their families, tell me that for the moderately to severely affected children with autism there is an obliteration of the 3rd space. There is only subject. Parents sense this when the autism manifests in infancy. And there is evidence that it can be diagnosed by 6 months. Many of the mothers in my practice have told me that they ‘knew something was wrong right from birth’. And just recently I had a case where the autism developed at around 15 months and the mother described the event with great sadness saying “All of sudden the light went out. He just wasn’t there.” With no other, there is no 3rd space.

Here’s an interesting conundrum. Children with autism are typically well attached to their mothers; there is good evidence for this in the work of Oppenheimer from Israel. In other words, the child with autism is bonded emotionally at a very deep biological level. But what I’m talking about is not about attachment per se; it is about moving from attachment to separation to being in the world i.e. entering the 3rd space of Winnicott. For children with autism the ‘other’ is missing. It’s as if they are merged with the world in an infantile state before separation. How do we help parents help their child become aware of the shared social separate world?

We do this by first merging with the child, joining the child. This is the theory of Stanley Greenspan MD, my mentor and colleague, who has described in detail how we develop what he calls ‘functional emotional development’. Greenspan says we must first share attention briefly—the 1st Functional Emotional Developmental Level (FEDLs); then we become engaged (the 2nd FEDL) for longer and longer periods of time; then two-way communication (3rd FEDL) will emerge. In these first three levels we have to join with the child’s most autistic behaviors and in doing so we bring the outside world in. We do not force the child out. This would create too much anxiety. We follow the child. We have fun by ‘speaking sensory’. We play using the senses, pure sensation; we smoosh, we squeeze, we spin, we swing the child in a blanket. We build the capacity for separation by helping the child with autism first create a sense of self. For the first time the child looks at another as if for the first time—eye contact, asking for more smooshing, more swinging. This whole process of bringing the child with autism into awareness of the world can take months even years. But slowly even the most severely involved child gains a sense of separation which is to say a sense of self. Slowly the child becomes aware of the world as separate, of the mother as separate. The 3rd space of Winnicott is created!

Then, guess what? The transitional object appears! Objects exist. People like mom, dad, brother exist as if for the first time. I have seen this so many times. The child might hold objects, carry his blanket, suck her thumb for comfort, love a favorite stuffed animal. The child now has a glimmer of a sense that there is a world outside, just a glimmer. The child with autism can now enter the third space! When this happens, it is like a small miracle. He or she becomes purposeful and takes mommy’s hand to get food or goes to the door to go out. Routines become familiar by action (bath water is running), then by name (“Time for a bath!”).

But hold on. It’s not time to celebrate yet. This is a very delicate process. Because children with autism want to keep the world the same (see the blog Autism and Addiction), they are prone to high anxiety. So be careful! This delicate, anxious sense of self that is emerging particularly in the young child with autism (but also all children) must be tenderly and playfully nurtured. We cannot pull the flower by its stem to make it grow; we must nurture the roots and it will grow on its own or the child can and will shut themselves down and go back into their autistic separate world very quickly and often many times a day. So, for me one of the biggest questions is: “How do we help the child with autism move into this fresh new world without too much anxiety?” How do we enter the 3rd space with joy? I’ll talk more about that in the next blog.

Winnicott, in his book Play and Reality, says that play and creativity “more than anything else makes the individual feel that life is worth living. Contrasted with this is a relationship to external reality which is one of compliance.” So, it is NOT through teaching, NOT through demands; NOT through rewards for success or compliance that we bring the child with autism into this potential space between him or herself and the world, but through play. And not just any play or even typical play. The play must not focus on the adult’s conception of play but be sensitive, quiet, a waiting, luxurious kind of play that accepts and follows the child’s intention and ideas and truly engages the child in fun playfulness. What I tell parents all the time is ‘when you accept your child for exactly where they are at, that is the fastest way to help them become the child you want them to be!’

So, play with your children in a way that is fun for them, not to achieve what you want for them. In fact, this is not a bad formula of play for any child especially in this age of ready-made toys and endless electronic distractions. If you do this, the child will grow and separate in a healthy way, and be happy in the shared social world with and then without his or her ‘blankie’. And Winnicott will be smiling down from developmental heaven.