This is a more personal, narrative exploration of the issues. There is an accompanying analysis of the diagnostic, technical and research issues in Autism and Attachment - Part 2
There is growing evidence that the rate of neurodevelopmental disorders (NDD) in parents and children involved in child protection (CP) cases is far higher than was ever thought, with one in thirty children with autism (ASD) being placed for adoption following Court proceedings. An important point here is that that research was looking at children with a diagnosis of autism: the question remains, how many children are in child proceedings where there are undiagnosed neurodevelopmental issues? We cannot know the answer to that but the information we do have (about children with identified such problems in proceedings and the difficulties there are with getting proper diagnoses of neurodevelopmental issues) suggests it may be worryingly high.
There a numerous factors here but there is perhaps one of particular importance. In essence, it is the idea that has taken hold that a multitude of things that are really very characteristic of NDD are somehow due to deprivation, attachment or other parental factors. The reality is, though, that are not really very similar at all - which raises the question of how this confusion has arisen.
To start with some basics, kids with anything like ASD (or what was called Asperger's) are odd or quirky or eccentric or however it might be described. The core problems they have are, by definition, related to (i) repetitive behaviours and restricted areas of interest and (ii) social interaction, development and communication. A lot of these kids talk, behave, interact, move, walk, smile, laugh and think in unusual ways. This is very obvious with, say, hand flapping but more commonly it is a wide range of characteristics that are displayed or affected in various ways - and sometimes it is a lot more subtle than hand flapping. And in essence, these are all genetically-caused entirely neurodevelopmental characteristics with almost no overlap with anything that could be described as attachment-related or environmentally-caused.
So when a child with all these characteristics presents for an assessment, the first thought has to be, what is going on for this child from a neurodevelopmental perspective? And I see perhaps hundreds of children like this every year. A lot of them are being brought by their very caring parents for private assessments because they want to understand their child and ensure they get the best support. I then see a large number of essentially identical children in family law contexts where the explanation that has been applied to the very same characteristics is that they are due to attachment, trauma, abuse, neglect and so on.
Now, those children may well also have experienced those things - but it cannot be right that those characteristics that could easily be seen in entirely benign family circumstances where a child has a neurodevelopmental disorder be attributed to environmental factors. In fact, I would say it is clearly wrong for the reasons explained in Attachment and Autism - Part 2.
So, what has happened here? I think several things. Firstly, the general descriptions of things that very disturbed kids and kids with ASD might do are somewhat similar. They don’t make friends, they can be aggressive, they lash out, they do things repetitively, they interact unusually, and so on. Secondly, the people involved in child protection processes will often have been given lots of training on attachment but perhaps none on neurodevelopmental disorders. Thirdly, people who work in child protection don't see the families where the child has an identified NDD but there is no hint of a CP issue.
So when these sorts of things are seen in a family where there are known problems, they are quite easily put down to abuse or neglect: there is some sort of superficial similarity and no-one has the experience to identify the neurodevelopmental component. The case goes to Court because things haven't changed, the child is fostered or adopted, and no-one is any the wiser.
For the avoidance of doubt, it is not that identifying the neurodevelopmental issues somehow means that abuse or neglect has not occurred - far from it. It is that there has often been no attempt to meaningfully distinguish the different causal components - or, in fact, any awareness that there might be competing explanations.
The issue of superficial similarity is perhaps rather important here. In fact, it is perhaps more of a descriptive similarly as, in reality, the presentation of a child with trauma or significant attachment problems is not really like a child with an NDD. The key point is perhaps that the effects of even in utero environmental factors do not replicate the sorts of genetically-driven issues that are seen in ASD-type presentations. In the end, there is a big difference between the problems caused by genes and the problems caused by environmental effects: pervasive oddity of the sort routinely seen in ASD is really nothing like the results of being badly treated. Abused and neglected kids display all sorts of issues but ASD-type oddity just isn't part of it: Indiscriminate stranger affection is about the closest it gets.
Again, to be clear, we know that significant causal factors in ADHD are environmental, including in utero, because early adversity impacts on the development of executive functioning. The same is true of a whole variety of neurodevelopmental issues. In essence, attachment is a neurobiological phenomenon: what happens in those early years changes your brain. But autism and its associated features just aren't. So the kid who walks on their tiptoes, makes strange noises, wrings their hands, uses funny voices, interacts strangely, doesn’t have friends, does things repetitively, is obsessed with things, was slow to write, still reads out loud at 10 and was speech delayed may have experienced abuse or neglect - but you can be pretty sure they are also just neuroatypical.
The discussion that often occurs around these issues can take the form of, But how do you know - couldn’t these things be due to neglect/trauma/attachment? The answer to the second part is often just, No, that's not what those problems look like. The difficulty is that this can be quite challenging for the person who hasn’t had to consider this before - because it means that they might have been wrong, not just about this child but every other one they have seen like them. Attachment often forms the bedrock of what they do and it could mean that core parts of their knowledge base have to be revisited. The point is that this isn't something about this child in particular and why the attachment model might be wrong in this case: in fact, the characteristics that comprise autism have been quite systematically and erroneously thought to be a reflection of deprivation-related disorders - and this is embedded in the assessment frameworks that are routinely applied in CP cases. The effect of this has been a self-reinforcing cycle where the ASD characteristics of children who have also experienced deprivation are taken to be attachment-related - which then perpetuates the idea that that is what attachment problems look like. The next child with such symptoms is assessed as having significant attachment problems, because it has come to be thought that that is what those symptoms mean, and so on.
Forty years ago or so, the vestiges of the refrigerator mother hypothesis were shaken off. This was the idea that autism was caused by how a child had been treated: we know that to be simply untrue. But we now have another problem, a sort of inverse refrigerator mother hypothesis: there's no mention of autism, but nonetheless you must have done something to your kid to make them like that.
Click here for Autism and Attachment - Part 2
Dr Joshua Carritt-Baker
