Clinical Observations of the Differences Between Children on the Autism Spectrum and Those with Attachment Problems: the Coventry Grid by Heather Moran (11/2/2010)
When a child has experienced a very difficult early life or serious abuse or trauma, it can be hard to tell whether the child has attachment problems or is on the autism spectrum or both. The problems they show may appear very similar on the surface.
The Coventry Grid discusses the similarities and differences between children on the autism spectrum and children with attachment problems and their response to interventions.
The child's response to therapeutic interventions and strategies, can reveal whether or not the child's issues are ASD or attachment related, or both. The danger of misdiagnosis is that the child might be excluded access from services or interventions that might help. The diagnostic process is subjective and there aren't any definitive tests, so there will always be some children who are inappropriately diagnosed.
Differences noted by therapists - working with children on the autism spectrum and children with
attachment problems
Therapeutic Relationship
One of the key differences noted by clinicians was the way a therapeutic relationship was used by the child. Professionals described a much more ‘emotional feel’to therapeutic relationships with children with attachment problems and a more ‘matter-of-fact feel’ to therapeutic relationships with those on the autism spectrum.
- Children with attachment problems
Therapists reported that relationships with this group often developed quite quickly, but that they had to work hard to develop and maintain more appropriate relationships (dependence and maintaining appropriate interpersonal boundaries were very difficult).
The children often emotional challenged the therapists and were resistant to the relationship boundaries the therapists were trying to establish and maintain.
The children generally arrived with some ability to make a relationship with another person (although usually in an idiosyncratic and inappropriate way). Part of the therapeutic intervention was to directly address these issues:
* helping the youngsters to understand their how they built relationships,
* why the relationships may have become unhealthily skewed, and
* how they might change things so that their future relationships could be more successful and healthy.
The relationship between the child and therapist was the vehicle for therapy - Children on the autism spectrum
Therapists working with youngsters on the autism spectrum described making great efforts to make the beginnings of relationships work in order to get the child to engage in therapy.
The children needed the therapists' active assistance to make a relationship with a professional. This involved helping the child to view contacts as being relevant and useful to him or her.
The maintenance of appropriate emotional boundaries was far less of an issue because the children were not usually setting out to test those boundaries. The issues were more focused on appropriate behavior for the room or for the situation.
The task was to make therapy relevant, often by involving children’s interests or obsessions because the relationship with the therapist was unlikely to be a significant motivator in the early stages of therapy
children with attachment problems.
Eating Issues Example:
Problems with eating are often mentioned in regards to both groups of children with temper tantrums and rigid, obsessive behaviors around eating. However, careful evaluation of the nature of these problems showed considerable differences in how, when and where they occurred.
- Children on the autism spectrumThe problems related to eating in children on the autism spectrum were often about the strong preferences related to physical sensations (such as texture and taste), the way food is organised on the plate, or its place in the child’s daily routine.
Problems with food were pervasive, occurring wherever the child was invited to eat, regardless of who was offering the food and where it was being eaten. Denial of offered food seemed to be related to taste and texture preference and not to who was offering it. - Children with attachment problemsThe provision of food often had strong emotional significance and was associated with relationships. Problems were most evident in relation to parents or carers, with more typical eating habits in situations with other adults.
Parents and carers often reported concerns about abstinence and gorging and these behaviors tended to be associated with deliberate (and planned) deceit such as throwing or giving away food, or hiding food and wrappers. Denial of offered food seemed to be with the intention of emotional hurt or emotional defense, something which requires an understanding of emotional relationships.
Differences between the two groups were considerable, even though the headline for both could be “obsessive and rigid patterns of eating behavior."
Both autism and significant attachment problems might be construed as developmental difficulties and both groups might be vulnerable to misdiagnosis, especially when they present with depression and anxiety or when they have very good intellectual abilities and relatively poor relationship skills.
Children with one or both of these diagnoses (on the autism spectrum or attachment problems) may look similar, but there are definite differences in the way their problems are expressed in daily functioning.
These differences imply that different assessment and diagnostic pathways and different treatment styles may be needed for the two groups, although there may be some types of intervention from
which they would both benefit (eg the use of visual timetables to reduce anxiety).
Heather Moran - a Consultant Child Clinical Psychologist who works within a Child and Adolescent Mental Health Service (CAMHS) and other professionals in the West Midlands 11/2/2010
Click here for the: (Revised Version of the Coventry Grid)
