Conference Coverage

Mismatch and repair technique adapted for autism


 

REPORTING FROM APA 2019

– Children with autism often struggle with repairing “messy” interactions with others, and this can impair their ability to communicate and develop properly. The interactive mismatch and repair technique, developed by Ed Tronick, PhD, when he was a researcher at Harvard Medical School and Children’s Hospital, Boston, may be able to guide communication development between an adult and a child with autism.

At the annual meeting of the American Psychiatric Association, Alexandra Harrison, MD, assistant professor of psychiatry at Harvard Medical School, described her experiences applying the technique to her work with autism patients, and showed a video of an awkward interaction she had with a 3-year-old boy with autism. By working to synchronize body movements with “Hal,” as well as inserting 1-second gaps between her statements, she helped him resolve an awkward moment, and Hal ultimately defused the tension by making a joke.

Hal managed to regulate his own uncertainty in the moment and navigate through tension. That small triumph has the potential to grow. “Once they’ve been able to secure some form of regulation with one or two or three individuals who are devoted to them, the hope is that this will spread and they will be able to regulate with individuals who are not as adjusted to them,” Gisele Apter, MD, PhD, a colleague of Dr. Harrison’s and professor of child psychiatry at Normandy Medical School, France, said in an interview. Dr. Apter moderated the session where the video was shown.

Dr. Tronick believes that the infant and caretaker grow together, making meanings together that are increasingly complex and coherent. That growth occurs in part through mismatch and repair interactions. Communication between infants and caregivers is nearly always a messy dance, with waxing and waning attention, changing intentions, and other dynamic factors leading to stops and starts, and awkward moments that the two must find a way to repair before carrying on.

These momentary mismatches, which happen all the time, are in fact a key element of childhood development, according to Dr. Apter. “There’s a lack of synchrony, and we want to get back on track because we push to communicate again. To do that, we have to repair the interaction, and one of the most beautiful things about development with this unbalanced couple is that the adult is generally there to support, to scaffold the child, but just one small step ahead of the infant so that it will enrich its development,” she said.

But a caregiver with depression or another mental illness, or a child with impaired communication development because of autism, can impede that natural process.

Dr. Tronick’s method aims to provide some structure to the interaction by likening the nonverbal part of the interaction to music and dance. There are vocal rhythms, tone, and pitch, and then there are coordinated patterns of movement, gaze, and facial expressions such as smiles or frowns. The idea is that developmental growth occurs when the infant and the adult create meanings through their interactions.

Such growth can occur in microprocesses – extended moments in which child and caregiver iron out a mismatch in intent or action. Resolving these situations, and then moving forward with the rest of the interaction, helps the child grow in complexity and development by acquiring new meanings.

One-second beats after each statement or sentence lead to predictability. “He can develop an expectancy, and he can anticipate my vocal turns, and that is going to be reassuring to him,” Dr. Harrison said during the presentation. It also allows the caregiver to think through a messy moment, to try something different if one action seems not to be working. “It’s very hard to know how to repair the messiness, because it’s actually not messy enough. It’s too black and white. Something works or it doesn’t work, whereas with most kids you can be a little messy and you have time to get back on track with them.

“With these children [with autism], it requires a level of awareness which is higher. It is helpful for the adult to try to adjust and learn to interact in a different way that is more attuned to the child,” Dr. Apter said.

In the video shown by Dr. Harrison, she and Hal are in the therapy/play area, and Hal’s mother has just left before he could say goodbye. He was very upset by this, but then turned to work building a “map” out of construction toys called H-links that he had been playing with, along with his mother, before she left. Throughout the video, Dr. Harrison attempts to synchronize her body movements with Hal’s, shifting her position when he shifts his, and these get out of alignment and come back in alignment at different times. Several times, body motion synchrony is followed by a statement from Hal.

Dr. Harrison sits on the floor next to him, with Hal faced away from her. At a loss for what to do, she makes a small pile of H-links next to her. Hal notices this, and then moves some of the H-links back to their original position.

Hal says, “The H-links don’t go together that much.”

“They don’t go together that much?” repeats Dr. Harrison.

“Yeah.” He takes more H-block pieces from her pile.

“You wanted to take my ones, too?”

At this point, there is an obvious mismatch, with Hal claiming Dr. Harrison’s H-blocks.

Hal smiles as he takes a few more H-blocks and then says, “Only for boys.”

Then his smile widens and he gazes directly at Dr. Harrison, who meets his with an expression of mock surprise.

“What?”

“Only for boys,” Hal repeats.

Dr. Harrison then strings a long a series of phrases, each separated by 1-second beats. Hal orients himself away from her, smiling slightly: “You mean only boys can play with these? ... Uh oh ... Guess that means ... I’m not allowed! ... Is that right? ... Oh, my gosh ... How did they ever make up that rule, I wonder?”

At this, Hal orients himself toward Dr. Harrison again and smiles widely this time. “You’re tricking me,” says Dr. Harrison, and he gazes downward, though toward her. “But I think you’re trying to tell me that you don’t want me to hand them to you ... You want to get them yourself. ... That right?”

“Yeah. No more giving me pieces,” says Hal.

“Oh, I’m glad I understood. ... I will not give you any more pieces.”

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