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Facilitating Attachment in Children With Autism Through Art

Therapy: A Case Study

Article in Journal of Psychotherapy Integration · June 2014

DOI: 10.1037/a0036974

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 Journal of Psychotherapy Integration © 2014 American Psychological Association
2014, Vol. 24, No. 2, 99 –108 1053-0479/14/$12.00 http://dx.doi.org/10.1037/a0036974

Facilitating Attachment in Children With Autism Through Art

Therapy: A Case Study

Huma Durrani
Inside Out Art Therapy, Singapore

Autism is a neurodevelopmental disorder that may be broadly defined as a develop-

mental disorder characterized by impairment in an individual’s verbal and nonverbal
communication skills. Autism manifests as multiple symptoms, such as inappropriate
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

social interaction, restricted interests, sensory dysfunction, self-regulatory issues, and

This document is copyrighted by the American Psychological Association or one of its allied publishers.

repetitive behaviors. This paper describes a case study of a 12-year-old boy, Tom
(pseudonym), with autism spectrum disorder who received art therapy for severe
sensory dysfunction and self-regulatory issues. In this case study, we hypothesize that
the presence of chronic sensory withdrawal may have impaired Tom’s attachment to his
primary caregiver, resulting in insecure attachment and subsequent social engagement
difficulties. We propose that an art therapy intervention that lasted over a period of 1
year may have facilitated sensory modulation and self-regulation in Tom, thereby
lowering his anxiety levels, aiding attachment to his therapist, and improving his social
engagement in general. As such, we suggest that in the context of children struggling
with autism, art therapy may be an important intervention worth further exploration and
study.

Keywords: autism, attachment, sensory dysfunction, self-regulation, art therapy

Children with autism display a large spec- observation of children and retrospective re-
trum of function and dysfunction ranging from views of videotapes and home movies. How-
having amazing talents to severe challenges. ever, as the importance of early diagnosis and
However, a common thread runs through the intervention has become evident, some longitu-
symptomology of autism spectrum disorder dinal studies have emerged (Volkmar et al.,
(ASD). Those suffering from this disorder are 2005).
characterized by impaired social interaction, Because of the complexity of the syndrome,
sensory dysfunction, self-regulatory issues, lim- there is no typical course of early childhood
ited interests, and repetitive and rigid behavior development in the autistic child. Although a
(American Psychiatric Association, 2000). Au- stereotypical child passes through normal stages
tism is often also associated with other disor- of early childhood development relatively eas-
ders, such as anxiety, depression, attention def- ily (Klin, Lin, Gorrindo, Ramsay, & Jones,
icit disorder, and motor incoordination or 2009), development of the child with autism is
dyspraxia (Baron-Cohen & Belmonte, 2005; marked by the emergence of two core features
Hill & Frith, 2003). of ASD: sensory dysfunction and impaired self-
Studies of early development of children with regulation. Because sensory dysfunction affects
autism are limited. This is because autism is the auditory, visual, vestibular, tactile, and pro-
generally diagnosed around 2 years of age, prioceptive areas in varying degrees depending
when autistic symptoms become more apparent on the particular autistic child, considerable
(Volkmar, Chawarska, & Klin, 2005). Research symptom heterogeneity naturally presents
in the last century has mostly relied on parental among children with autism. This results in a
wide range of individual differences in impair-
ment along the autistic spectrum and unique
sensory profiles among autistic children (Brock
Huma Durrani, Inside Out Art Therapy, Singapore.
Correspondence concerning this article should be ad-
et al., 2012; Dunn, 1999). Therefore, although a
dressed to Huma Durrani, 11 Rajasa II, Kebayoran Baru, capacity for self-regulation in typically devel-
DKI 12110., Indonesia. E-mail: [email protected] oping normal children occurs because of matur-
99
 100 DURRANI

ing executive functions and interaction with the tistic children to include communication, social-
environment, children with autism suffer many ization, early intervention, and sensory
self-regulation difficulties. These range from regulation. We argue that through multisensory
disturbed sleep patterns to impulsivity, irritabil- art activity and attunement with the art therapist
ity, and hypersensitivity. All of these sensory in a safe holding space, art therapy beneficially
difficulties may play a role in inhibiting the affected Tom’s sensory dysfunction and self-
social and emotional development in the autistic regulation difficulties. Through lowering his
child that is dependent on positive interaction anxiety levels, a more self-regulated Tom may
with the environment (Gomez & Baird, 2005). have become more able to form an attachment
In addition to the development of sensory with the art therapist. Attachment to the art
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

integration/functioning and self-regulation, a therapist might then have provided Tom with an
This document is copyrighted by the American Psychological Association or one of its allied publishers.

core feature of normal early childhood develop- experience of a substantial human bond similar
ment is the ability to attach to a caregiver. This to a normal mother-child relationship or attach-
attachment has been hypothesized to lay the ment to a primary caregiver—a bond that is
blueprint for future relationships in later life critical for a healthy psychoemotional develop-
stages (Bowlby, 1951). Forming in the first year ment in a child.
of life, attachment quality is determined by the
interaction of the infant with his or her caretaker Literature Review
and is dependent on attunement between both
parties (Howe, 2005). A child with sensory dys- Autism
function often blocks sensory input from the
environment as a defense against unpleasant Autism, a term not commonly understood a
sensations that cause anxiety and distress (Go- few decades ago, is now a familiar developmen-
mez & Baird, 2005). One could argue that such tal disorder with known worldwide prevalence.
sensory dysfunction and self-regulation diffi- ASD is diagnosed based on a core triad of
culties limit the autistic child’s capacity to ben- clinically observable symptoms that involve im-
efit from attuned others, which in turn may paired social interaction and communication
result in a child with autism suffering from an abilities as well as the presence of restricted,
impaired capacity to attach to caregivers and repetitive, and stereotyped behaviors and inter-
being impeded from optimal communication ests (American Psychiatric Association, 1994).
and exchange with the environment. All may According to Hill and Frith (2003), autism var-
limit the autistic child’s availability for attach- ies in severity, and it is modified by many
ment in his early years (Gomez & Baird, 2005) factors, including education, ability, and tem-
and negatively affect the child’s subsequent de- perament. Autism’s clinical picture can also
velopment in areas of communication and emo- change over the course of development within
tional development. A study conducted by Se- one and the same individual. In addition, autism
skin and colleagues (2010) using the “strange is frequently associated with other disorders,
situation” and its variants shows that although such as attention deficit disorder, motor incoor-
children with autism can form secure attach- dination, sensory dysfunction, and psychiatric
ments with their caregivers, insecurely classi- symptoms such as anxiety and depression. Con-
fied children with autism outnumber the se- temporary research implicates environmental
curely attached children without autism. factors together with genetic susceptibility as
the probable cause of autism (Martin, 2008).
Aim
Sensory Dysfunction and Self-Regulation
The aim of this paper is to illustrate the role Difficulties in ASD
that art therapy may have played in facilitating
attachment and social functioning in a young One of the central characteristics of ASD is
autistic boy, Tom. Because art therapy is a dysfunction in the sensory processing system of
multisensory, multifaceted approach, it can be the autistic child. Many studies provide evi-
tailored to the individual needs of a particular dence of abnormal sensory processing in indi-
child with autism. Martin (2009a) has high- viduals with autism (Baranek, Foster, & Berk-
lighted treatment goals of art therapy with au- son, 1997; Kern et al., 2006; Liss, Saulnier,
 FACILITATING ATTACHMENT IN CHILDREN WITH AUTISM 101

Fein, & Kinsbourne, 2006; Tomchek & Dunn, impoverished for the child with autism mainly
2007). The sensory system or sensory organs because of their sensory processing difficulties.
and the autistic individual’s senses of sight, By not being able to regulate overreactive or
hearing, smell, touch, and proprioception pro- underreactive responses to sound, touch, vision,
cess diverse input from the environment in an smell, and proprioception, the autistic child’s
atypical way. capacity to connect to others is interfered with
According to Greenspan and Weidner (1998), as they experience sensory deregulation and
when some part of the sensory system goes immense anxiety (Gomez & Baird, 2005).
awry, it causes dysfunction. Most children with
autism have this sensory dysfunction. In some Attachment
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

autistic children, one sense may be more af-

This document is copyrighted by the American Psychological Association or one of its allied publishers.

fected than others. Greenspan and Weidner Attachment theory emerged from the joint
(1998) elaborate and explain that “these systems work of John Bowlby and Mary Ainsworth,
enable us to feel balanced and safe as we move, who were in turn both influenced by the work of
sit, and stand, to let other people get close, and Freud and other psychoanalytic thinkers. Ac-
to protect ourselves if we feel endangered” (p. cording to Bowlby (1951), a mentally healthy
36). They suggest that normal sensory function- infant “should experience a warm, intimate, and
ing is required for normal social functioning. continuous relationship with his mother (or per-
Human beings are continually exposed to input manent mother substitute) in which both find
from the environment during development. satisfaction and enjoyment” (p. 13). Referring
Therefore, it is inevitable that an autistic child to this as a mutual regulatory system, Arrington
with sensory dysfunction will have difficulty and Cherry (2007) state that the “system unfolds
regulating their interaction with their surround- when activated by certain cues and conditions
ings. Interaction with the environment might from either the mother or the infant. A mother
lead to a sense of heightened anxiety in the who provides a fragile infant with consistent
autistic child. Because of this unpleasant expe- feelings of safety through sensory experiences
rience, the child is likely to withdraw from the of gentle touch, warm liquid, a motherese voice,
environment to limit their sensory input. Hence, and presence, builds core states of well-being
this withdrawal from the environment also leads while reducing anxiety, fears, sadness and
to distancing from relationships and subsequent stress” (p. 29).
impairment in the psychoemotional develop- According to Howe (2005), a safe and secure
ment of the child (Gomez & Baird, 2005). attachment is a biological means of survival and
Gomez and Baird (2005), listing four levels a means of controlling anxiety. Prior and Glaser
of self-regulatory development, cite attachment (2006) add that attachment is “based on the
as the second level that occurs between the ages need for safety, security and protection” (p. 15).
of 2 and 7 months. We argue that in children From a dynamic perspective, the first attach-
with autism, the need to self-regulate sensory ment relationship is considered crucial to the
discomfort by withdrawal hampers social and establishment of a secure base for the child and
emotional development and leads to impaired his or her future relationships (Bowlby, 1951).
interaction with the environment. Therefore, any disturbance in the infant’s at-
A personal account of these difficulties is tachment to the mother may have undesirable
offered by Temple Grandin, a well-known per- long-term consequences for the child through-
sonality suffering from autism, who has referred out his or her life.
to the social and emotional consequences that Attachment may be classified as secure or
resulted from defects in her own sensory sys- insecure (Wood, 1984). Insecure individuals
tem. She described how painful her overwhelm- may suffer from anxiety in their attachment
ing auditory experience was and how impossi- relationships and find it difficult to regulate their
ble it was for her to think about emotions when anguish and arousal (Howe, 2005). Research on
all she could do was protect herself from the attachment and autism shows that although chil-
onslaught of terrible noise (Grandin & Scariano, dren with autism are able to form secure attach-
1986). ments, the parent-child relationship for an au-
We hypothesize that the normally rich tistic child and their caregiver often “reflects
ground for developing relationships becomes less flexible, sensitive, and synchronous inter-
 102 DURRANI

active behaviors as a result of the social impair- drive to connect to others needs to be roused
ment of children with autism” (Rutgers et al., before developing other facets of communica-
2007, p. 860). Naber and colleagues (2007) tion (Osborne, 2003).
support these findings, adding that these rela- Art therapy is a means to arouse communi-
tionships are greatly hampered by developmen- cative drives within the autistic child who, ac-
tal delays and arousal difficulties. Therefore, cording to studies, may find processing objects
there is evidence that points to a relationship easier than faces, “so in theory the art object
between autism and disrupted early attachment. may be more useful than the adult’s words”
(Martin, 2009a, p. 74). Art-making can also be
Art Therapy: A Brief Introduction fun and provide leisure while achieving devel-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

opmental goals (Martin, 2009a). Martin adds

Art therapy, a relatively young profession,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

that “sensory regulation is often less stressful

was “born” in the second half of the 20th cen-
for the client in art therapy because the art
tury. It was developed by individuals, mostly
provides a product to focus on beyond the pro-
artists themselves, who believed in the healing
cess of integrating uncomfortable sensory expe-
power of art-making and imagery. In the early
riences” (Martin, 2009b, p. 188). Adding to
20th century, thinkers such as Sigmund Freud
that, Emery (2004) argues that
theorized the emergence of the unconscious
through imagery and dreams. Karl Jung also The use of nonverbal expression through the experi-
proposed his theory of the collective uncon- ence of making art encourages children with autism to
begin to represent their experiences. Forms represent
scious as one that was rooted in symbolism and objects and the very act of drawing with intention may
imagery. Both psychoanalysts, Freud and Jung, encourage attachment to the object. Children create art
realized the inadequacy of language in reflect- because it is rooted in the need to relate to their world.
ing our inner, emotional world. Art therapy (p. 147)
developed from the idea that the process of
Art therapy may also facilitate the autistic
image-making and creative expression heals
child’s awareness of self through relatedness
and transforms unpleasant life experiences
with the artwork. This may again help in devel-
through symbolic communication (Malchiodi,
oping object constancy because of the concrete
2002).
nature of the artwork that can be remembered
As the profession grew, it borrowed theoret-
and referred to over time (Emery, 2004; Martin,
ical knowledge from the counseling and psy-
2009a). Because children with autism also often
chotherapy disciplines to enhance the clinical
suffer from significant deficits in the areas of
skills of art therapists. Although art therapy has
language and communication, art therapy as
its roots in psychoanalytic and psychodynamic
opposed to language-based approaches may of-
theory, it has since embraced other philosophies
fer the child with autism a more befitting ther-
and approaches, such as cognitive art therapy,
apeutic modality.
Gestalt and Jungian existentialist art therapy, and
Art therapy, a nonverbal form of creative
narrative or phenomenological art therapy. Art-
expression, has been used to help individuals
making remains central to the practice of art ther-
from many age groups heal and find relief from
apists who enrich their understanding by integrat-
mental health problems, gain insight, achieve
ing knowledge from other disciplines (Moon,
personal growth, find relief from emotional con-
2002; Vick, 2012). The fundamental belief that
flict, resolve issues, and increase their sense of
underpins art therapy is that arts-based mediums
well-being (Malchiodi, 2012). As a modality,
and the creative process all possess inherent qual-
art therapy makes use of a wide range of art
ities of healing that can access and affect uncon-
materials with visual and tactile diversity. As
scious processes inaccessible through verbal
such, art therapy can offer various means to
forms of expression.
engage the senses of sight, hearing, touch,
Art Therapy and ASD smell, and proprioception, potentially encom-
passing the entire range of the human sensory
It is well established that children with autism experience. A large variety of media in a wide
lack the innate drive to communicate or interact spectrum of colors and textures may be used as
with others and may even reject attempts by a means of sensory regulation for the tactilely
others to communicate orally. Therefore, the hypersensitive or hyposensitive child. Clay,
 FACILITATING ATTACHMENT IN CHILDREN WITH AUTISM 103

paint, goop, sand, and/or play dough may be Through attunement of the art therapist and
manipulated, beaten, and stretched to provide the child’s own sensory experience, autistic
proprioceptive input. Music can also accom- children can also improve their imitation skills,
pany art-making to target the auditory areas. motor skills, and coordination. These skills can
Different materials such as tin foil, bubble wrap, further bolster emotional awareness and under-
or Styrofoam can be crushed or pressed to pro- standing, emotional regulation, and social skills
duce various sounds. Scented paint, pencils, (Gabriels & Gaffey, 2012).
crayons, and glue engage the sense of smell. Gilroy (2006) enumerates several studies
Art therapy also has the potential to adapt to conducted by art therapists with children on the
the variability of individuals presenting with autism spectrum using art therapy as an inter-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

unique profiles of autism whether they are ver- vention. These studies also support the efficacy
This document is copyrighted by the American Psychological Association or one of its allied publishers.

bal or nonverbal, able or disabled, resistant or of art therapy in the social, behavioral, and
willing. This is because the scope of art therapy developmental areas of the child (Evans &
is wide. The variety of material available for Dubowski, 2001; Henley, 2001). More empiri-
artwork and a range of techniques can be tai- cal studies on art therapy for autism are still
lored to the needs of the hypo- or hypersensitive called for.
child. Because each child with autism has a According to Gomez and Baird (2005), most
varied and individual sensory profile, an art of the research in autism has been in the areas of
therapist needs to be familiar with an autistic sensorimotor development, communication,
individual’s particular profile(s) to prudently and cognitive and social aspects, and it has been
use the art material. This would necessitate done retrospectively. Most therapies for chil-
working in collaboration with the child’s occu- dren with ASD focus on the cognitive and be-
pational therapist to better understand the havioral aspects of the disorder, often neglect-
child’s sensory issues or to have access to the ing the psychological implications for
development. As such, research concerning so-
child’s developmental and psychological as-
cial and emotional development is rather lim-
sessments if they are available. Important ques-
ited.
tions that would need to be answered would
What follows is a case study of art therapy
relate to the child’s sensitivity and reactivity
intervention with Tom, a 12-year-old autistic
toward particular sensory input. The therapist boy with a complicated attachment history
who is familiar with the sensory profile of an within which attachment and sensory develop-
autistic child may be able to open the door to mental implications are highlighted.
communication and relational development.
Because of its concrete and visual nature,
Case Study
art-making can also aid a client with autism by
offering avenues of expression that are poten- The aim of the following offered case study,
tially soothing. This is because the individual which is qualitative in nature, is to generate
can engage in alternative, yet still sensory, interest in the emotional development of the
modes of repetitive artistic expression. Current child with autism. It also aims to generate fur-
art therapy approaches with children with au- ther study in the area of sensory dysfunction,
tism are believed to provide a venue for the attachment, and autism. It does this by attempt-
autistic child’s self-expression and self- ing to explore the potential of the sensory aspect
regulation and to provide nonverbal visual tools of art-making within the therapeutic space. This
to facilitate social skills and communication. space was created by an art therapist who had
According to Martin (2009a), art-making may the additional advantage of background training
satisfy an innate aestheticism in these children in psychodynamic psychology, which enabled
in addition to providing channels for their self- her to work with the conscious and unconscious
stimulatory and repetitive behaviors. She adds aspects of art-making. A core premise of using
that “lack of imagination and abstract thinking a dynamically informed art therapy with an
skills is one of the three major deficits of autism autistic child is to recreate the nurturing space
yet is the one least often addressed by most of early childhood that may have been missing
therapists; art therapists have a unique ability to from the early experience of the child with
improve these skills” (Martin, 2009b, p. 188). autism (Osborne, 2003). The art therapist is
 104 DURRANI

equipped to provide that safe space and the Tom’s parents had a hostile relationship and
holding environment that mirrors an optimal were separated. Tom and Ron lived with their
mother-child relationship. father, who traveled frequently. As a result, the
This paper focuses on the multisensory and twin boys were mainly looked after by a nanny
regulatory aspect of art-making. Several limita- who had been with them for 10 years. Tom’s
tions must be noted. First, only background mother was known to be aggressive and had
information from Tom’s occupational therapist confessed to practicing “tough love” with the
was available because input from Tom’s family twins. According to Tom’s father, she barely
was negligible. As such, because the parents spent time with the children and her visits were
were unwilling to share much information, not infrequent. It was reported by Tom’s occupa-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

much is known about Tom’s childhood and tional therapist that Tom’s anxiety appeared to
This document is copyrighted by the American Psychological Association or one of its allied publishers.

developmental history. Because of strained escalate around his mother and that he seemed
family dynamics and noncooperation by Tom’s to be more attached to his father.
parents, it was also not possible to conduct pre- After interviewing Tom’s mother and father,
and posttherapy interviews in any detail. Most it was evident that both parents were in extreme
of the input provided by the parents was through conflict about Tom’s course of therapy and that
brief verbal exchange after the therapy sessions. his future therapeutic direction was also under
Furthermore, no psychometric data were avail- contention. An interview with the nanny re-
able to gauge the efficacy of the art therapy vealed that she was overworked and found han-
intervention. The outcome of the intervention dling both children difficult, a task exacerbated
was assessed through the therapist’s observa- by the boys’ parents’ conflict.
tion of Tom’s participation in the sessions and
through corroboration by Tom’s nanny and par- Presenting Issues
ents over the course of 1 year of art therapy. As
such, this case study is offered as a narrative The first few sessions of art therapy were
account of Tom’s progress in art therapy. None- used to informally assess Tom’s presenting is-
theless, we hope that it provides convincing sues. Combined with an analysis of Tom’s case
evidence of the effectiveness of art therapy for history and presenting circumstances, it was
children with autism. hypothesized that his attachment may have suf-
fered from severe disruption in early childhood
Background because of parental conflicts and absences as
well as his diagnosis. Tom had severe sensory
Informed consent was obtained from Tom’s dysfunction and self-regulatory issues. It was
parents to use his case for educational purposes. observed in the first few sessions that Tom had
Tom, one of a pair of twin boys, was born minimal eye contact, very little joint attention,
prematurely in the second trimester of his moth- and that his receptive language was extremely
er’s pregnancy. He and his brother Ron suffered restrictive. According to Seskin et al. (2010),
from various postnatal complications and were this provided some evidence of Tom’s problems
diagnosed with ASD at an early age. Tom’s with attachment because children on the autism
brother Ron had a more complicated condition spectrum who are securely attached are more
than Tom because of comorbid cerebral palsy. likely to engage in joint attention, have better
Tom’s main diagnosis was ASD. Both twins receptive language, and make requests more
were nonverbal until age 12, when Tom’s art frequently than children with autism who are
therapy intervention commenced. insecurely attached.
Tom had been engaged in occupational and Because of his sensory impairment, Tom
speech therapy for many years before he was would likely have protected himself from sen-
referred for art therapy to address high anxiety. sory stimulation from the outside world by
His case history was mostly communicated to withdrawing himself from interaction with his
the art therapist by his occupational therapist, environment (Naber et al., 2007). Thus, at-
who had been working with him for many years tempts at mirroring and attunement from his
and was also familiar with Tom’s family dy- primary caregivers would have been consis-
namics. tently disrupted by Tom’s experiencing such
 FACILITATING ATTACHMENT IN CHILDREN WITH AUTISM 105

attempts as sensory overload, further hampering Art Therapy Sessions

pathways to a more secure attachment.
Tom had been receiving occupational therapy Art therapy sessions with Tom were initially
for several years before the art therapy interven- held once a week. The first 10 sessions lasted 30
tion began. Although the occupational therapy min each. During the first art therapy session,
may have reduced sensory defensiveness in Tom presented with a high degree of arousal
Tom to some degree and opened doors for at- and anxiety. He had very fleeting, if any, eye
tachment to form, the family dynamics would contact; minimally engaged with the therapist;
not have made it easy for attachment to opti- and was unable to sit still at the art table. After
every few minutes, Tom would jump on the
mally develop. It was apparent that it was ex-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

trampoline and flap his hands. On occasion, he

tremely difficult for Tom and Ron’s parents (or
This document is copyrighted by the American Psychological Association or one of its allied publishers.

would bang his head on the floor or wall, seem-

the nanny for that matter) to meet the psychoe- ingly out of anxiety or frustration. During most
motional needs of their two severely disabled of the early sessions, Tom engaged in self-
children. Although Tom did seem more at- stimulatory and repetitive behaviors, making al-
tached to his father than his mother, it could not most no eye contact with the therapist. He was
be determined how much time the father had not forced to make any art because it was some-
been able to give the infants in their early child- thing new to him and it was considered likely
hood years. Furthermore, Tom’s nanny came that at this early stage he may have felt threat-
into his life when he was around 2 years of age, ened by an unfamiliar routine and the presence
when the initial stages of attachment had al- of a stranger in the person of the therapist.
ready passed (Gomez & Baird, 2005). Her emo- It became apparent in the first few sessions
tional availability to the boys would also have that to engage Tom in art-making it would be
been limited by her own capacity to regulate her necessary to first establish a rapport with him.
frustrations related to the complicated task of Only then could he be approached to engage
looking after all of the daily needs of both boys. with the art materials. Hence, the therapist made
For all of the above reasons, we assumed that it art in front of Tom to indirectly familiarize him
was probable that there had been significant with the art materials and the process of art-
disruption in Tom’s attachment to any of his making. This routine lasted for a few sessions to
three primary caregivers in his life. create a sense of safety and predictability for
The occupational therapist’s report indicated Tom. Slowly, Tom began to pay attention to the
that Tom had severe sensory impairment that therapist. He moved closer to the therapist, who,
greatly hampered his self-regulatory capacities. encouraged by his approach, gradually “lured”
He was tactilely defensive and sought a lot of him to come into contact with the art material.
movement, especially jumping on the trampo- Tom began to engage with the material by pour-
line and flapping his hands. His sense of pro- ing different colors of paint over the paper and
prioception was also impaired. He was also spreading it with brushes or rollers before run-
ning off to the trampoline for a sensory break.
reported to have sensitivity to certain sounds.
The therapist followed Tom’s pace and mir-
Although Tom had been doing speech therapy
rored his movement and body rhythm just as a
for a few years, he was still nonverbal and was mother responds to her child by attuning to her
only able to hum his favorite nursery rhymes. We child’s cues. Therefore, when Tom poured paint
assumed that Tom’s highly anxious behavior in onto the paper, the therapist did likewise, taking
the therapy center could be attributed to his sen- Tom’s lead and following him, at times sharing
sory dysfunction, his lack of self-regulation, and the paper with him, and at others working par-
insecure attachment. allel to him. This was an attempt to attune to
Tom and Ron also had a reputation for being Tom’s body language and emotional state. It
very hard to handle because of their difficult, also gave Tom an experience of having a con-
aggressive behaviors. Moreover, dysfunctional nected effect on the therapist’s behavior, which
family circumstances added to the complexity could give him a more anchored experience of
of their situation, with the result being that being present in the environment and the ther-
many therapists were reluctant to take their apist in it (Meehan, Razzaque, Insko, Whitton,
case. & Brooks, 2005).
 106 DURRANI

Tom’s engagement with the material length- home as long as she sat with him. This suggests
ened over the sessions, and he began to show some evidence that Tom was connecting his
preference for paint and roller over other medi- enjoyment with art-making with his conscious
ums by picking up the bottle of paint from experiences of human connection (attachment).
among the crayons or the roller from among the Tom seemed very happy at the end of most
brushes. His concentration and duration at mak- art therapy sessions to show his artwork when
ing art also increased. Session after session, either parent or nanny were called in and
Tom made art, enjoying the flow of the paint, praised his efforts. This again suggests that art
either brushing it or pouring it directly from the therapy was scaffolding his wish for human
bottle, and his eye contact with the therapist connection. His self-stimulatory behavior re-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

became longer and more meaningful over the duced significantly during the sessions, and
This document is copyrighted by the American Psychological Association or one of its allied publishers.

sessions. Tom continued expressing himself in a head banging became a rare occurrence. Tom’s
somewhat repetitive manner, but now in an ob- parents and nanny said that he also seemed to be
ject-constant manner through art-making. For calmer at home, and the speech therapist re-
the most part, the same type of artwork was ported improvement in Tom’s speech develop-
made using Tom’s favored medium. However, ment in the year that Tom was doing art ther-
it should be highlighted that, for Tom, the in- apy.
tentional goal of the sessions was not to develop Tom’s art therapy sessions lasted for 1 year.
his image-making or symbolic thought, but pri- It appears that art therapy helped him to engage
marily for him to enjoy the session, engage in an activity that was pleasurable to him in an
presently and sensorily with the art materials, environment where he felt safe in the presence
and to begin to let down his defenses and com- of activity and persons and to express himself
municate with the therapist. and assert his choices. This sense of safety and
Care was taken to keep Tom’s arousal levels the ability to express himself through his art,
at optimal levels during the sessions by manag- especially when language had been completely
ing his accessibility to the art material by in- absent at the onset of the art therapy, may have
creasing or decreasing the amount of paint he lowered his anxiety level and created an oppor-
was allowed to use. New material was intro- tunity for him to bond with the therapist while
duced prudently to desensitize Tom’s aversion using a communicative medium other than a
to certain textures, monitoring his levels of anx- verbal one. As such, the artwork may have acted
iety. At times, nursery rhymes and favorite as a buffering and bridging agent (Martin,
songs were used to maintain flow of communi- 2009a) for the interaction between the therapist
cation by singing or dancing with Tom. and Tom. Exposure to sensations that he en-
joyed and gradual desensitization to textures
Reported Outcomes that he was averse to may also have helped
modulate his sensory functions. Positive inter-
Within 6 months, Tom was sitting at the action with the environment may have also
worktable for 30 min at a stretch, with the aided self-regulation. Tom’s body language and
whole session lasting for 1 hr. More impor- engagement with the therapist showed his at-
tantly, Tom’s communicative abilities had im- tachment to her. Despite the lack of verbal
proved drastically. Not only was he able to communication, there seemed to be an unspo-
choose medium, color, and mode of application ken understanding—an attunement between the
by grabbing the tools that he wanted, he was two. Their relationship over the period of a year
also able to indicate when he wanted to end the may also have created an internal working
session and go home by humming his goodbye model (Howe, 2005) for Tom for building fu-
song and waving his hand. He had also learned ture relationships to whatever degree possible
to say “no” to indicate rejection. for him.
Around 8 months into the art therapy ses-
sions, on recommendation from the therapist, Conclusion
Tom’s father set up an art space in his home so
that Tom could also engage in art-making away The lack of evidence-based practice in the
from the art therapy room. Tom’s nanny com- field of art therapy is a disservice to a therapeu-
municated that he seemed to enjoy making art at tic modality that has huge implications for in-
 FACILITATING ATTACHMENT IN CHILDREN WITH AUTISM 107

dividuals with ASD, among others (Martin, American Journal of Occupational Therapy, 51,
2009b; Osborne, 2003). As mentioned earlier, 91–95. doi:10.5014/ajot.51.2.91
most studies of early childhood autism are ret- Baron-Cohen, S., & Belmonte, M. K. (2005). Au-
rospective and focus mostly on sensorimotor tism: A window onto the development of the social
and the analytic brain. Annual Review of Neuro-
and cognitive abilities. There is a lack of re-
science, 28, 109 –126. doi:10.1146/annurev.neuro
search on the psychoemotional aspects of autis- .27.070203.144137.
tic children from which problems with interper- Bowlby, J. (1951). Maternal care and mental health.
sonal relationships may stem. Bulletin of the World Health Organization, 3, 355–
A major difficulty for empirical research in 534.
the area of ASD is the variability that exists Brock, M. E., Freuler, A., Baranek, G. T., Watson,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

within the autism spectrum. This makes it hard L. R., Poe, M. D., & Sabatino, A. (2012). Tem-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

to quantify data from many variables within perament and sensory features of children with
each individual child with autism. Comorbidi- autism. Journal of Autism and Developmental Dis-
ties and treatment sensitivities make large-scale orders, 42, 2271–2284. doi:10.1007/s10803-012-
1472-5
studies on treatment of this disorder, although Dunn, W. (1999). Sensory profile. San Antonio, TX:
an empirical necessity, a gargantuan task. As The Psychological Corporation.
such, it is important not to disregard qualitative Emery, J. M. (2004). Art therapy as an intervention
data such as the case study presented of Tom. for autism. Art Therapy: Journal of the American
Individual case studies such as this also offer Art Therapy Association, 21, 143–147. doi:
avenues for further validation of art therapy as 10.1080/07421656.2004.10129500
an intervention for particular cases of autism. Evans, K., & Dubowski, J. (2001). Art therapy with
Quantitative studies using potential measures children on the autistic spectrum. London, United
for obtaining more empirical data do exist. Kingdom: Jessica Kingsley.
Naber and colleagues (2007) have used the Gabriels, L. R., & Gaffey, J. L. (2012). Art therapy
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acknowledge the significance of evidence-based Focus on Autism and Other Developmental Dis-
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10.1007/s10803-006-0255-2 Received July 8, 2013
Naber, F. B. A., Swinkels, S. H. N., Buitelaar, J. K., Revision received February 26, 2014
Dietz, C., van Daalen, E., Bakermans-Kranenburg, Accepted March 19, 2014 䡲

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