Dr. Rick,A few days ago I was reviewing a web presentation on attachment. Nothing new but a nice refresher. This morning I was reviewing a comprehensive assessment on a child diagnosed with PDD NOS. I was also thinking about some thoughts a co-worker had recently shared, about co-occurring dd and cmh disabilities and it struck me that the diagnosis of autism or something in the spectrum almost requires an attachment issue. I also thought about the LOVAAS approach and autism treatment in the clinical or community setting with non family members who sometimes change frequently. Where there has been some corroboration of positive outcomes with LOVAAS in IQ, those positive outcomes have not generally included behavior. The best overall outcomes must include family participation and even LOVAAS/ABA has now acknowledged the importance of joint attention. Yesterday I also read an article about the longing that many if not most children in the spectrum have, in spite of inappropriate or ineffectual attempts, for relationships. (Hope that wasn't too long of a segue.)If most children with autism also have attachment issues, is center based or even community based treatment ultimately counter productive for the overall and long term benefit of the child and family? From a mental health perspective you would NEVER prescribe a child with an attachment disorder, especially a young one, with 30, 20, or even 10 hours per week in a center or community setting with strangers and without a family or caregiver present. That would be almost unfathomable. Your thoughts, please?Pete
Hi Pete,I fully agree. Drilling a young child 30-40 hours per week is developmentally inappropriate and can interfere with multiple developmental processes including attachment, affect, initiation, and autonomy. ABA is good for cognitive gains but depends on naturalistic settings for generalization and attainment of true social abilities. The fundamental relationship in ABA type interventions is: 'Do this. Good job' which is a very impoverished form of relationship. The adult leads. Child led interventions promote affect, initiation and autonomy--three very high values for me. Joint attention is just the beginning. I'm afraid we've let the tail wag the dog. By using empirical approaches only without a respect for what we know to be developmentally necessary, we've been able to teach discrete skills at the cost of developmental integrity. You can quote me on this. Hope this helps.Take care,
Rick
Richard Solomon MD
Medical Director
Ann Arbor Center for Developmentaland Behavioral Pediatrics
Added note from Pete: This does not mean that children with Autism have an attachment disorder. Children with Autism generally do development strong attachments: however it is often an irregular and sometimes difficult attachment. The developmental needs of the child as well as the relationship and what is called "joint attention" are central to the needs of the child and family.
