Play Therapy with a Child with Asperger Syndrome: A Case Study¹

Abstracts

This study's objective was to discuss the psychotherapy process of a 12-year old boy affected by Asperger Syndrome, a pervasive developmental disorder, cared for in a public outpatient service. The therapeutic setting and the box of toys had to be modified and made more flexible to address the child's peculiarities. The bond established between the therapist and patient and the importance of dealing with the differences between Self/Not-self are discussed. The treatment, adapted to the conditions of a public outpatient service, contributed to the child's communication and interaction skills, which shows the importance of discussing psychodynamic psychotherapy with this population and how to implement it.

Asperger's Syndrome; child psychotherapy; psychotherapeutic processes

Este estudo objetivou discutir o processo psicoterapêutico de um menino de 12 anos de idade com Síndrome de Asperger, um transtorno global do desenvolvimento, atendido em um ambulatório de psicoterapia de um hospital público. Osetting terapêutico e a caixa lúdica tiveram que ser modificados e flexibilizados para atender às peculiaridades da criança. São discutidos o vínculo terapêutico e a importância de se manejarem as diferenças entre eu/não-eu para a terapia. Percebeu-se que o atendimento, adaptado às condições do ambulatório público, contribuiu para a capacidade de comunicação e de interação da criança, fato que aponta para a importância do debate sobre a psicoterapia psicodinâmica com esta população e formas de realizá-la.

Síndrome de Asperger; psicoterapia da criança; processos psicoterapêuticos

La finalidad de ese trabajo fue discutir el proceso psicoterápico de un niño con 12 años de edad con Síndrome de Asperger, un trastorno global de desarrollo, atendido en un ambulatorio psicoterapéutico de un hospital público. El escenario terapéutico y la caja de juegos tuvieron de ser modificados para las necesidades y peculiaridades del niño. Fueron discutidos el vínculo con la terapeuta y la importancia de trabajar las diferencias entre el yo y el no-yo. La atención, adaptada a las condiciones de un ambulatorio público, contribuyó a la capacidad de comunicación y interacción del niño, hecho que indica la importancia del debate sobre la psicoterapia psicodinámica con esa población y formas de ponerla en práctica.

Síndrome de Asperger; psicoterapia infantil; procesos psicoterapéuticos

According to the 10^th edition of the International Classification of Diseases (ICD-10), pervasive developmental disorders are "a group of disorders characterized by qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities" (Organização Mundial de Saúde {OMS}, 2003, p. 367). These abnormalities are a constant feature of affected individuals and are present in all situations.

This group of disorders includes childhood autism, atypical autism, Rett syndrome, and Asperger syndrome. The last is somewhat similar to autism, however, it is not associated with retardation, or language or cognitive development deficits. Abnormalities usually persist throughout adolescence and adult life, with potential psychotic episodes at the onset of adult life (OMS, 2003).

In terms of the prevalence of Asperger Syndrome, Klin (2006) indicates that it ranges from two to four out of each 10,000 inhabitants, with a proportion of nine men to each one woman. The author notes that in addition to the fact that Asperger Syndrome has been more frequently diagnosed in recent years, it has also been frequently attributed to children with normal or high IQs, as opposed to children diagnosed as autistics, as happened in the past. Regarding its prognosis, Klin asserts that individuals with this syndrome can occupy professional positions and support themselves but losses in the social sphere are considered to be permanent.

Assumpção and Pimentel (2000) note the complexity involved in the differential diagnosis of pervasive developmental disorders. These conditions demand a multidisciplinary approach considering the fact there is a large number of "sub syndromes" linked to the autistic spectrum that require studies designed to understand such disorders. Accordingly, when Tamanaha, Perissinoto and Chiari (2008) studied the construction of concepts of childhood autism and Asperger Syndrome, they stressed that "the way to fully understand these disorders and their etiologies still requires much clarification on the part of scholars." (p. 298)

Psychoanalytical theories develop different ways to understand autism and its etiology and varied intervention strategies directed to individuals affected by pervasive developmental disorders. Alvarez (1992/1994) endorses the idea that autism has multiple causes. This author considers it to be necessary to understand how innate factors interact with environmental aspects. Therefore, hereditariness and environment revolve around each other. She notes that its onset may be due to neurological dysfunction, however, the psychological deficit configured from these dysfunctions needs to be described and explored to culminate in an understanding that combines various innate, environmental and psychological factors.

Still in the field of psychoanalysis, Borges (2006) develops associations of autism to family relationships, especially emphasizing the maternal figure. The author argues that the "work with autistic children should be based on the possibility of movement of affection, on restoring the mother's ability for anticipatory illusion, and finally, the emergence of a subject of desire." (p. 143)

According to Araújo (2004), based on Winnicott's thinking, one can understand "autism as a matter of emotional immaturity, that can occur when the maturing of the child is somehow interrupted, either by the inadequacy or insufficiency of the environment in the face of the child's needs." (p. 45) Even though the author does not dismiss the importance of elements external to the environment-individual relationship, he notes the role of the mother's unconscious affection as an etiological factor of autism. Hence, he understands that, during clinical practice developed with autistic individuals, it is necessary to provide "emotional support to parents in the exercise of their parental roles" (Araújo, 2004, p. 57).

Psychotherapy of Pervasive Developmental Disorders

Pervasive developmental disorders harm both the individuals affected (Assumpção & Pimentel, 2000; Borges & Shinohara, 2007; Klin, 2006) and their families, which often experience an emotional overload (Cuvero, 2008; Fávero & Santos, 2005). For this reason, there is a need to "better identify the needs, both psychological needs and those related to public policies designed to alleviate suffering that emerges from this condition" (Fávero & Santos, 2005, p. 367).

The psychoanalytical literature reflects upon the etiology of pervasive developmental disorders, noting not only factors of organic origin but also those of an emotional order. Given this context, studies report the gains obtained by individuals affected by pervasive developmental disorders (Alvarez, 1992/1994; Marques & Arruda, 2007), and their families, through the implementation of therapeutic interventions grounded in the psychoanalytical and psychodynamic framework. These interventions help families to complete their mourning for the ideal child and can also alleviate stress arising from care required by the child (Fávero & Santos, 2005).

Excepting the significant differences in the clinical conditions and clinical evolution between Down syndrome and pervasive developmental disorders, we mention the study by Couto, Tachibana and Aiello-Vaisberg (2007), conducted with mothers of children with Down syndrome. The authors report two major concerns of these mothers that are also concerns of mothers of children with pervasive developmental disorders: the disappearance of their perfect child and a concern about what will happen to their children when they are no longer there. They also stress how the diagnosis influences the family's dynamics.

Orsati, Mecca, Schwartzman and Macedo (2009) in turn note that children and adolescents with pervasive developmental disorders, in terms of perceiving human faces, "present a pattern of exploration of faces different from those with normal development" (p. 354). They spend less time looking at the eyes and face as a whole, a fact that may hinder understanding social situations and lead to socially inappropriate behavior. Being aware of such characteristics as present in individuals with pervasive developmental disorders is important for therapists willing to care for this population, since these are characteristics of patients that may cause suffering and discomfort among professionals unaware of them.

Based on his analytical experience with psychotic and autistic children, Tustin (1972/1975) observed the importance of these children to realizing that explosive violence that threatens everything that exists is contained within the therapeutic setting. Even with such a contention, it is possible to see that these individuals cling to autistic habits, and therapists are required to be firm if they want the individuals to fully abandon such habits.

It is unlikely, at least at the beginning of treatment, that autistic children will understand words, nonetheless, these children learn more than may seem apparent at first glance. It is important to choose words very carefully since meanings should be short and concise for interpretation, while therapists should be prepared to repeat them many times, with the same or varied formulations (Tustin, 1972/1975).

The child will have the opportunity to experiment with an object that listens and speaks, which is important to introducing the child to the habit of speaking, and even more relevant, to listening. The child realizes someone is trying to make contact, is capable of tolerating the frustration caused by his/her lack of response, and does not discourage nor give up seeking verbal communication. When interpreting, the therapist "is lending a mental device to the child, which s/he will use until it becomes able to develop her/his own." (Tustin, 1972/1975, p. 165) However, it is important that the therapist refrain from interpretations, unless the material produced by the child provides candid and clear evidence that what is being said makes rational sense. Autistic children produce much less evidential material than neurotic children.

Difficulty in communication and in social interaction is a remarkable aspect of pervasive developmental disorders, a fact that also hinders the establishment of therapeutic bonds. Marques and Arruda (2007) address this subject when they defend the view that the establishment of bonds between the child and the therapist should be the initial focus of psychotherapy with these children. For that, they highlight the importance of the therapeutic setting, discrimination between self/not-self, and the function of maternal holding performed by the therapist.

The scientific literature reports a lack of descriptions and discussion concerning the psychodynamic psychotherapy in children with the specific diagnosis of Asperger Syndrome, though there are some references for interventions with individuals affected by autism and pervasive developmental disorders in general. Hence, an experience report concerning the psychotherapy of an individual with Asperger Syndrome is relevant and can enrich understanding and improve the intervention strategies employed.

This study's objective was to discuss the psychotherapeutic process of a 12-year old boy with Asperger Syndrome, a pervasive developmental disorder, cared for in a psychotherapy outpatient clinic of a public hospital. This study follows the qualitative research method in the Human Sciences (Turato, 2003) in the format of a case study. For that, clinical material concerning psychodynamic play therapy will be used.

Method

Participant

The study included one 12-year old boy diagnosed with Asperger Syndrome who attended psychodynamic play therapy in the psychotherapy outpatient service of a public hospital.

Instruments

Psychotherapy play therapy was the instrument used to conduct this case study. It was performed in a public service child psychotherapy unitconnected to a child psychiatric outpatient service. Such a connection enables a multidisciplinary staff to provide care within the same facility to those requiring extended care.

Psychotherapeutic care was provided by a therapist attending a program specialized in child psychotherapy. The activities lasted two years and the weekly sessions took about 45 minutes. Because the influence of the family on the children's emotional development is acknowledged (Sei, Souza, & Arruda, 2008), there are situations in this outpatient clinic in which parents receive special attention provided by another professional, while in other cases, the therapist himself/herself provided occasional guidance, when necessary.

The care provided to the child and interventions were based on the psychoanalytical framework with the inclusion of an individual ludic box, which symbolizes the patient's inner world. This technique enables the child to express his/her fantasies, anxieties, psychological defenses and feelings, in general, through the objects present in the box, drawings and play. The intervention was based on the assumptions of child psychoanalysis (Aberastury, 1962/1982; Alvarez, 1992/1994; Ferro, 1995; Klein, 1955/1991), adapting the setting for the context according to the possibilities a public facility presents (Aguirre & Arruda, 2006; Arruda & Carneiro, 2006; Hildebrand & Arruda, 2008).

Procedures

Data collection. Data were collected through play psychotherapy implemented with the study's participant. The sessions were transcribed by the therapist providing care to the patient and supervised by another professional in the field.

Data analysis. Data were analyzed by consulting the transcriptions, making connections with the literature on the topic. Analysis was based on authors within psychodynamic approach who discuss psychotherapy with individuals affected by pervasive developmental disorders, especially autism and Asperger Syndrome.

Ethical Considerations

This study was approved by the Institutional Review Board of the Medical Sciences Faculty, Universidade Estadual de Campinas (process No. 444/2008). This study is part of a larger project addressing Child Psychotherapy, implemented in a child psychotherapy outpatient service. All ethical guidelines were complied with during the study's development and publication, in which the anonymity of the patient and his family was ensured. A free and informed consent form was approved by the institutional board and signed by the participant's mother.

Results

Leonardo was a 12 year-old preadolescent, diagnosed with Asperger Syndrome, and referred to psychotherapy by the psychiatric department of a public hospital. Before initiating the psychotherapy, the psychologist responsible for providing care interviewed the mother to record the child's clinical history. The father did not attend the initial interview or any of the play therapy sessions due to the impossibility of being absent from his professional activity, he reported.

Leonard's psychotherapy process lasted two years, a period during which the mother received occasional clarification or guidance, either requested by the mother or by the therapist. There were rare absences, where the mother always gave notification prior to the absence or justified it. The mother and patient always arrived before the scheduled time.

Leonard was the couple's third and last child; his two older sisters had already been married for some time and had their own families. In order to proceed with the child's psychiatric treatment, the mother abandoned her job and city, moving with her husband and child to a neighborhood near to the hospital, to which she and the child had to take a bus. The father is currently a public servant hired by the city's government and the mother is a homemaker.

In regard to Leonard's main antecedents, childbirth was normal and lasted 12 hours. From birth, he had a skin allergy over his body, with a rash that was not resolved by any of the physicians consulted. He was breastfed until three months of age and was weaned when the mother returned to work. He rejected cow's milk and had intestinal problems up to the age of three, which required the use of diapers up to that time.

He did not talk until the age of three. He only emitted some sounds that were only understood by the mother, who answered his requests. He spoke few words by the age of four and joined school without, however, socializing with other children. He was tested by a psycho-pedagogical professional with negative results. He was enrolled in the first grade at the age of six and half years old. He was an agitated and inattentive child but showed good intellectual development. He attended speech therapy from the age of three up to nine years old.

He was attending the sixth grade when he started psychological treatment. His peers at school called him "crazy". He used to choose younger children to relate with, without considerable advantages, according to his mother's opinion. He kept a friendship with only one child, who accompanied him in all his activities. He had a close relationship with only one teacher, who had taught him for many years, and everyday, he would greet her with a kiss. The mother was puzzled over this closeness to the teacher on his part and always reproved him for it. With the exception of this friend and this teacher, Leonard was unable to establish social relationships outside the family.

At home, he showed a predilection for comic books and his hobby was "inventions" related to electricity and hydraulics. His inventions, brought to the hospital, were very creative and known by the psychiatrics who cared for him. This interest was shown to the therapist in the game time, when he drew the bulbs and the sockets of the therapist's office. He refused to play with the toys in the ludic box saying he would only play with his inventions.

In the first session, Leonard brought a mixer that actually worked because it was connected through wires to a battery. He said he did not want the items from the ludic box alleging, "men do not play." He refused to take the key of the ludic box home and signalized to the therapist she could keep it. He left the room before the time scheduled for the session to end because he wanted to stay with his mother, a behavior that was repeated during the first months of therapy.

The ludic box was reformulated for the second session and from then on, it was called "Leonard's inventions box." The play material he did not want was removed and material used in the construction of his inventions such as scrap, wire, tools, treads, among others, were made available to him. Leonard accepted this reformulation and was allowed to add other items he brought from home to the ludic box if desired.

After this technical change, Leonard started using the material to make his "inventions". He used cans and string to make a drum, which was initially offered to the therapist and then to his mother.

Over the course of the therapy, he showed great interest in a game called "Engineer", during which he made "very tall towers", repeatedly overturned. In one of the sessions, the therapist pointed out to him that he dropped the pieces on her so he could approach her. He responded saying he wanted to play hide and seek. The therapist had to keep her eyes shut while Leonard said he would hide and when she opened her eyes, she saw he was under the table, with his head very close to her legs. This play was repeated during this session and during a long period of the therapy process.

The psychologist's notes showed that Leonard wanted to get closer to the therapist, know and touch her body. In the first interpretations concerning this content, he usually would leave the room and seek his mother. Hence, Leonard could not at that point respond to the therapist's interpretation, getting close again and showing he was still felt very threatened by the absence of his mother. As the bonds got stronger and the child increasingly trusted the psychologist, he asked to repeat the play, getting closer to the therapist without feeling the need to leave the room to seek his mother.

He also brought his "inventions" he made at home to the sessions. In this context, a phase followed where inventions were built that were then usually given to his mother. Afterwards, he made a watch with Styrofoam ball, with numbers and hands painted with gouache and offered to the therapist. He was able to get physically close to the therapist to "measure the size" of her wrist. The therapist gave him a radio on his birthday (a procedure never used before in this service), to be used in his inventions and returned the gesture by giving the therapist a gift made by his mother. There were demonstrations that the bond between Leonard and the therapist was being established, though he continued his behavior of constructing objects for his mother.

The bond with his mother was intense and she reported that the child slept with her in her bed whenever the father was away. The interest for proximity of this nature was also perceived in the therapeutic relationship, since Leonardo created situations to get physically and intimately close to the therapist, especially when he dropped and picked up the pieces of the Engineer game that fell close to her body. However, unlike what happened at home, there were restrictions and the therapist pointed the differences between self/not-self (Leonardo-therapist). When limits were imposed, Leonardo was able to respect them without touching the therapist and move on to a playful activity, a fact that shows a symbolic shift.

The repetition of the game of dropping the pieces on the therapist was understood in the sense that, for him, this play seemed to have the same meaning interpreted earlier: seeking to get closer to the therapist. Leonardo got aroused with this play and even had erections and, when impeded from touching his genitals or even masturbating, he interrupted the play and went back to the inventions. Based on this situation, it was understood that his inventions were used either as a representation of sexual content, or a way for him to deal defensively with his unconscious desires, to sublimate them.

Over time, he managed to verbalize some sexual content and fantasies, trusting his dreams to the therapist. Sometimes, they portrayed the proximity of Leonardo to other people, sometimes the therapist was present in his dreams, and he was able to talk about this approximation between the two.

In regard to the sexual content of his dreams, there is one situation in which he asked the therapist to guess about what he had dreamed. For that, he gave her clues about the subject: "It starts with P", he said, "then E, N, I, S." The therapist answered she understood that the content of his dream was related to his sexual organ. Afterwards, Leonard asked what she wanted to talk about in regard to it. The psychologist answered that she understood he was trying to find answers with the therapist for things he had doubts about, including sexual subjects. As he listened to this, he stood up and went to seek his mother.

Over the months, improvement in his disposition to remain in session was perceived, without him constantly leaving the sessions. Hence, he could construct a tie of trust with the therapist capable of supporting his permanence in sessions, during the entire interval proposed for that purpose, without checking where his mother was, as had occurred at the beginning of therapy.

Given the bond established, which was the key element of this treatment, any interruption of sessions, such as vacations and holidays, were presented in advance. In one of the times the therapist was on vacation, already in the second year of treatment, Leonardo was able to tell the therapist to rest, in an attitude that showed he consented to the distance that would be established between them.

In regard to the repercussions from the way Leonard interacted and dealt with the external and family environment, a timid but growing ability to distance himself from his mother was observed. This situation was perceived by the mother, who reported to the therapist in the second year of treatment that her child had gone on a short trip with friends from their church without requiring her presence, a fact that had never occurred before.

The mother observed and shared with the psychologist that he had started to take showers by himself, starting shutting the bathroom door, without requiring her assistance, as opposed to the bathing situation up to that point. It is worth noting that, despite the fact the mother was oriented by the therapist to no longer shower her son, nor to allow him to sleep in her bed whenever the father was away, nor applying ointment to his intimate parts, among other behaviors, the mother was reluctant to let him be more independent. Finally, Leonardo also started riding his bike more frequently around his neighborhood.

Due to the normal practices of the institution, there is a change of professionals linked to the service every two years, and Leonard was going to be cared for by another therapist. There was a transition process during the months that preceded the change of therapists. He initially manifested his desire to interrupt the treatment due to difficulties assimilating the change. However, after some sessions, he started to ask who would be his new therapist and what were her characteristics, in a movement of acceptance of this new process, maintaining his psychotherapy.

Discussion

The Asperger Syndrome is a pervasive developmental disorder in which there is a smaller degree of language and cognitive development deficit when compared to childhood autism. This difference is remarkable in this case because the problem was focused on social relationships, without any major harm in the intelligence and learning spheres.

In general, the literature points to the language deficit with implications for the therapeutic setting. In the case of Leonardo, there was a good development of language, despite the difficulty in establishing self/not-self limits. These limits were tested during sessions, whether as attempts to explore the therapist's body or leaving the room to contact his mother. Leonard and his mother, Leonard and his therapist, were different individuals, and this perception received attention in the course of the psychotherapy.

The setting also served to moderate his anxieties, enabling the symbolization and elaboration of his subjective issues (Tustin, 1972/1975). There was a need, given the child's refusal to accept the ludic box and his constantly leaving the office, to modify and make the therapeutic setting more flexible, according to Leonardo's specificities. Over the course of the therapeutic process, the possibility of Leonardo remaining in the office for the entire session without demanding to leave showed the establishment and maintenance of a tie of trust with the therapist, one of the main aspects of the proposed therapy, especially due to the difficulties faced by Leonardo in establishing social relationships.

One topic that emerged and was worked with in various sessions was related to sexual content and fantasies. These were connected to the maternal figure and were transferred to the therapist. On some occasions, when he had erections or wanted to masturbate in the office, the therapist needed to intervene, but did it so in a way he could still address this content and its latent meanings, shifting to material inside the box (especially to his inventions) or enabled him to talk freely about his fantasies that fueled these attitudes. When this sexual content appeared this way, the sessions were anguishing for both Leonardo and the therapist. Nonetheless, the ability to talk about them reduced his anxiety and enabled him to shift them, in a creatively manner, to his inventions.

We acknowledged that the reality of public outpatient services demand the adaptation of resources, and in the case of this service, we opted for qualifying therapists to work with children through a specialization program. This format requires therapists to be changed every two years, a situation that is not recommended or desired when caring for individuals with pervasive developmental disorders. Despite the context, we observed in this case, that the child can be prepared in advance for the arrival of a new therapist, which favored the establishment of bonds with the "new" therapist.

Final Considerations

Based on the case study presented, we assert that psychodynamic play therapy is a relevant tool to intervene with children with Asperger Syndrome in order to address losses experienced in the field of social interactions. Hence, the treatment enabled and favored the establishment of bonds between patient and therapist, contributing to the patient's ability to establish and improve his bonds outside of the therapeutic setting.

Moreover, it is known that public health services do not always have the staff necessary to offer psychological and multidisciplinary care for the long term, and this study presents a strategy to implement an intervention adapted to this context. For that, we promoted a specialization program addressing child psychotherapy two years in duration, which enabled qualifying therapists and expanding the service to this population. Additionally, even though we based the intervention on knowledge from child psychoanalysis, its theoretical and technical principles were adapted to the facility's capabilities, which enabled increasing the number of beneficiaries who could not afford the costs of such treatment via private services.

The conclusion is that the experience of this case study could be considered in other services, adapting it to the contexts and particular characteristics of each facility and service. Hence, research addressing psychodynamic play therapy could be expanded in order to develop interventions that consider difficult and complex clinical situations in more depth, as is the case of children with Asperger Syndrome or other pervasive developmental disorders.

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Publication Dates

• Publication in this collection
  Apr 2013

History

• Received
  14 Dec 2009
• Reviewed
  09 May 2012
• Accepted
  28 Nov 2012