Misreading the Child
Behaviour is not a simple window but a complex encryption of pain
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I’m just back on the Substack after a couple of busy months finishing a book about autism, out in September. This dovetailed with the Freud Memorial Lecture at the Freud Museum in Vienna, on the theme of ‘Freud and Neurodiversity’. It was a great honour to be invited to do this, and so moving to be in the Freud house on Bergasse, which has had a superb refurbishment a few years ago and is a remarkable place to visit.
Freud would certainly have been very interested in the autism debates today. Although not much has been written about this, he had authored three volumes on infantile cerebral paralysis - nowadays known as cerebral palsy – a group of neuromuscular conditions that have a high co-occurrence with autism. With a neurology clinic for child patients three days a week for over a decade, Freud would thus have seen many autistic kids.
We also know that in the early 1930s, an American couple with an autistic son visited Freud to ask for his help. He said that he didn’t know exactly what could be done, but referred the boy to his student Editha Sterba, one of the pioneering Viennese analysts working with children at the time. Sterba had published an account of what is perhaps one of the first analytic treatments of autism, published first in German then in English translation in ‘The Psychoanalytic Quarterly’ in 1936.
The paper is fascinating to read today, combining old school analytic frustrations with remarkable innovations in technique. When five year old Herbert would count the blocks she set out for him rather than play with them at the start of sessions, she decided to deliberately miscount them, telling him the ‘wrong’ number. Herbert would then correct her, creating a dialogue around what seemed to be a self-absorbed, uncommunicative activity. And when he whispered apparently nonsensical syllables, she would create her own nonsensical chain of half-words, mirroring his own yet with a slight consonant change, again inciting him to challenge her. Through these techniques, he was able to engage with her and the therapy.
By the 1940s, child analysts, psychologists and psychiatrists had almost all given up traditional techniques and were experimenting and innovating, trying to find ways to create contact with the child and foster an atmosphere of attunement. They would sing interpretations to the kids, use lullaby rhythms, exaggerated prosody, and play rough and tumble. Freud, who was never a stickler for rigid technical rules, would no doubt have been impressed with these creative, lively new approaches to analytically inspired therapy.
When we look at the cerebral palsy books, he doesn’t have too much to say about how psychological treatment can be helpful, yet ends the third volume with an endorsement of educational measures which, he believed, could be useful for the ‘mental functions’ of children with palsy. There are also quite a few references to how psychical shock might play a causal role during pregnancy or in the neonate’s life, yet he is cautious, and lists this as only one factor among others which are far more common.
But where Freud’s careful clinical eye is especially relevant here is his comment on the innervation of facial muscles. In cases of diplegic paralysis – so bilateral – he notes the frequent problem of innervation of the muscles in the face which are central to the expression and communication of emotion. The compromised musculature, however, is not bilateral, like the more general palsy, and so attention may be drawn away from it. It presents, rather, an asymmetry, so that it will seem as if the child is not experiencing or expressing emotion, or reacting in an odd way, to generate a misreading of the child’s mental state and an underestimation of their capacities.
And this question of reading the child’s affective expressivity is exactly what later autism researchers would focus on. Whether due to a lack of innervation of facial muscles or some other neurological issue, caregivers may find it hard to understand what the child might be communicating, and so miss the cues necessary for the vital dialogues that foster growth at the start of life. If a baby fails to show an emotional response to, say, being smiled at or rocked or caressed, this will most probably have an effect on how the caregiver then relates to them, in subtle ways which developmental researchers have studied microscopically.
Similarly, if a baby is fighting with the experience of gravity, as Lauretta Bender and later Jean Ayres suggested, or battling colonic pain, all their focus may be on this, so that they will not be able to attend to the activity that they are ‘supposed’ to be focusing on: feeding, reaching, exploring etc. It looks like the baby is not interested or withdrawing, when in fact it might simply be that all their energy is engaged elsewhere. Even sitting might be a dizzying feat, as some autistic people describe, and they have to do everything they can to find equilibrium even if, to adults around them, it seems as if they are perfectly comfortable and well supported.
These cycles of misreading might compound each other, and make the mutual legibility of behaviour more and more obscure. Each party misunderstands the other, or is confused and disoriented by them, a situation which might in itself make withdrawal all the more likely. But the key is that this is not an original withdrawal, but an effect or product of unsuccessful attempts to engage. Recognising the different levels here seems crucial: an initial set of often physiological difficulties, and then the effect of these on how baby and parents read each other – so translation problems.
When Gunilla Gerland would push her hands into her mouth, jerk her head, bite into her own flesh and that of others, and press her back and neck against walls, this might have seemed like bizarre inexplicable behaviour, some sort of fit or an act of aggression. Yet as she was able to explain later, she would bite other people to dull the intense sensitivity she felt in her teeth, which was connected to the constant pain she experienced in her spine and nape of her neck, a fusion of “icy heat” and “digging fiery cold”. She had no words to describe this torment, and could only act in desperate attempts to dull it.
Whereas older autistic subjects may sometimes be able to communicate something of their pain, infants are not in a position to do this, and usually it is very careful parental and medical scrutiny that can offer clues. One of the reasons this is often so difficult to diagnose is that pain can manifest in a different sensory system to where it is originating. Carly Fleischmann, for example, would run round in an acutely agitated state “like an overwound toy”, unable to stop, jumping and shrieking for hours at a time.
It was only much later, with the aid of her keyboard, that she was able to explain that she did this in order to cancel out the terrible pain in her arms and legs that she was unable to treat in any other way. She would hit herself “to stop this feeling”, and the many well-intentioned medical interventions that aimed to stop her from this frenzied behaviour and self-harm were thus aiming in the wrong place: they were trying to remove her treatment of the pain rather than the pain itself.
Freud encouraged us to read behaviours not as simple windows to some self-evident internal state but as often complex encryptions of pain and trauma which require deciphering. This seems all the more urgent working with pre-verbal children who need those around them to engage in the work of translation, and to acknowledge that what might look like self-absorbed withdrawal may actually include attempts to communicate.