The diagnosis of what is now called autism spectrum disorder (ASD) is in many ways very simple as there are only two core components. But it is also fair to say that it is one of the most complex and misunderstood diagnostic areas.
The two core components relate to behaviours/interests and social communication/development. However, it is also the neurodevelopmental disorder (NDD) that has the most complex and frequently comorbid presentations. People with ASD just tend to have a wide range of information processing (i.e. brain) abnormalities that impact on many areas of functioning.
The diagnostic system also changed in 2013, at least for the DSM - something that is described in detail in
Why the confusion about autism and dyslexia?. That has caused a reasonable amount of additional confusion and complexity but it is entirely clear that what is not intended is somehow to suggest that the person who has most of the relevant characteristics (but not all) does not have an NDD of that sort. The first question in any diagnostic process is,
Does this person have clinically significant problems or deficits? If the answer is yes, they should end up with a diagnosis - and what then follows is the differential diagnostic process to work out what it should be (or what combination it should be). See:
Understanding Diagnostic TerminologyDiagnoses and the Diagnostic Process
Considerations when Configuring Neurodevelopmental Services and Undertaking Related AssessmentsNeurodevelopmental Disorders: A Guide to Making Sense of them So, looking at the current DSM diagnostic criteria for ASD and attachment disorders, some interesting parallels stand out.
Autism Spectrum Disorder
Diagnostic Criteria 299.00 (F84.0) | Reactive Attachment Disorder
Diagnostic Criteria 313.89 (F94.1) | Disinhibited Social Engagement Disorder
Diagnostic Criteria 313.89 (F94.2) |
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive):
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social
approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures: to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. | A. A consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers, manifested by both of the following:
1. The child rarely or minimally seeks comfort when distressed.
2. The child rarely or minimally responds to comfort when distressed.
B. A persistent social and emotional disturbance characterized by at least two of the following:
1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers. | A. A pattern of behaviour in which a child actively approaches and interacts with unfamiliar
adults and exhibits at least two of the following:
1. Reduced or absent reticence in approaching and interacting with unfamiliar adults.
2. Overly familiar verbal or physical behaviour (that is not consistent with culturally
sanctioned and with age-appropriate social boundaries).
3. Diminished or absent checking back with adult caregiver after venturing away, even
in unfamiliar settings.
4. Willingness to go off with an unfamiliar adult with minimal or no hesitation. |
It seems clear at this stage that there is some real connection between these things: looking across the three diagnosis, there are some striking similarities. For example, 'abnormal social approach' in ASD clearly sounds like it could include 'reduced reticence in approaching and interacting with unfamiliar adults' - and it would be correct to think they are not really very distinguishable. There are several such examples of this.
However, the critical thing is what happens next…
Autism Spectrum Disorder
Diagnostic Criteria 299.00 (F84.0) | Reactive Attachment Disorder
Diagnostic Criteria 313.89 (F94.1) | Disinhibited Social Engagement Disorder
Diagnostic Criteria 313.89 (F94.2) |
B. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at
least two of the following, currently or by history (examples are illustrative, not exhaustive):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behaviour (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g.,strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).
| C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic emotional
needs for comfort, stimulation, and affection met by caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behaviour in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder. | B. The behaviours in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behaviour.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behaviour in Criterion A (e.g:, the disturbances in Criterion A began following the pathogenic care in Criterion C). |
Let's work through these carefully. Firstly, the ASD diagnosis goes on to require a range of things to do with repetition and restriction. However, these simply do not feature in the other diagnoses
because they are not really characteristic of deprivation-related disorders.Next, the attachment disorder diagnosis specifies as an absolute contraindication that the child must not have ASD. To be clear, this is saying that these diagnoses are mutually exclusive - and
you must not diagnose Reactive Attachment Disorder (RAD) in children with ASD. The question then is, why?
There are a few parts to this answer. One is that it could be saying something along the lines of,
These things could quite easily get confused and they shouldn’t, so let's make them mutually exclusive or,
One of these disorders inherently involves the other so both diagnoses are not needed (which was the situation with ASD and ADHD until the DSM-5 in 2013)
. But that's not quite right here. The more specific answer is that, where a child has a disorder that fundamentally impacts on their ability to form relationships, develop socially and engage with other people - and it is clear that that disorder is due to genetic factors (i.e. it is ASD-type) -
then you cannot also diagnose an attachment-related disorder predicated on a deprivation history because the attachment disorder loses its validity in that context. That is not to say that children with ASD cannot also have been severely deprived, just that you cannot say that there is an attachment disorder in those children because one of the premises for identifying such a disorder is that there isn't also an NDD that fundamentally relates to social development.
So, we have two very important parts here: (i) ASD-type NDD involve a wide variety of things just not seen in RAD and (ii) where those things are observed, such that it is clear the child has an NDD of that type, do not apply attachment models (because they are no longer valid).
The question then arises about what to do when a child with possible ASD has also been severely deprived. How do you tease this apart?
The answer comes from a number of things. Firstly,
to what extent do they meet Criterion B of the ASD diagnosis? If the answer is to any reasonable degree then the likelihood of it being an NDD is really quite high.
Secondly, there are a wide variety of associated characteristics that are frequently seen in ASD that are just not part of the deprivation model, such as these from the DSM-5:
- Even when formal language skills (e.g., vocabulary, grammar) are intact, the use of language for reciprocal social communication is impaired in autism spectrum disorder.
- These difficulties are particularly evident in young children, in whom there is often a lack of shared social play and imagination (e.g., age-appropriate flexible pretend play) and, later, insistence on playing by very fixed rules.
- Many individuals with autism spectrum disorder also have intellectual impairment and/or language impairment (e.g., slow to talk, language comprehension behind production). Even those with average or high intelligence have an uneven profile of abilities. The gap between intellectual and adaptive functional skills is often large.
- Motor deficits are often present, including odd gait, clumsiness, and other abnormal motor signs (e.g., walking on tiptoes).
Having done all this, it is then reasonable to draw conclusions about the relative weighting of the NDD and environmental factors - and where there is clear evidence of an ASD-type NDD, attachment models should be disapplied. To be clear, this is not just some sort of logical distinction but is important because, whatever sort of deprivation might have occurred, any normal link with attachment is fundamentally broken by the NDD -
and the application of attachment models in such circumstances will lead to erroneous conclusions.So, what sorts of assessments are needed here? As well as comprehensive assessments of the behavioural characteristics that comprise the core criteria of ASD, it is essential that a full neuropsychological assessment is completed. Without this, there is no way to know to what extent the additional indicators are met. The assessments must include the full range of core cognitive, executive functioning, motor skill and attainment factors as only then can the unevenness of a child's development be determined. It is that unevenness that so often clearly points to neuroatypicality as opposed to intellectual delay due to deprivation: where there are really quite profound deficits but only in a few areas, that simply cannot be explained by an environmental model (except in cases of more narrow ADHD where there has been early deprivation). This isn't rocket science - but it is brain science and we have the knowledge to get it right.
Dr Joshua Carritt-Baker
