AS and attachment disorder

[Alma]

Hi, does anyone have any experience of a dual diagnosis of AS and attachment disorder? My 14yr old stepson has had a difficult time with his natural mum (before and after he came to live with us aged 6). We only managed to get his diagnosis about a year ago and I thought that the AS had been difficult to diagnose because of the attachment issues. Now I'm puzzled because I've read about incorrect AS diagnoses when in fact the problem was AD. I've read around and there are a lot of similarities. I try really hard to support J (I've given up work to try to support him better) but he does everything he can to be unpleasant to me and basically treats me with contempt. He is pleasant and charming to everyone except me, his Dad and his paternal grandmother but is especially nice (sometimes excessively) to other adult females e.g. aunts, my friends, female teachers etc. I feel as if he is searching for a mother figure but he just doesn't want it to be me. I know we've also got teenage issues going on and most kids are difficult at this time but I feel at the end of my tether and because I'm so upset, I know my behaviours and reactions are not helping.

[Karen A]

Hi, does anyone have any experience of a dual diagnosis of AS and attachment disorder? My 14yr old stepson has had a difficult time with his natural mum (before and after he came to live with us aged 6). We only managed to get his diagnosis about a year ago and I thought that the AS had been difficult to diagnose because of the attachment issues. Now I'm puzzled because I've read about incorrect AS diagnoses when in fact the problem was AD. I've read around and there are a lot of similarities. I try really hard to support J (I've given up work to try to support him better) but he does everything he can to be unpleasant to me and basically treats me with contempt. He is pleasant and charming to everyone except me, his Dad and his paternal grandmother but is especially nice (sometimes excessively) to other adult females e.g. aunts, my friends, female teachers etc. I feel as if he is searching for a mother figure but he just doesn't want it to be me. I know we've also got teenage issues going on and most kids are difficult at this time but I feel at the end of my tether and because I'm so upset, I know my behaviours and reactions are not helping.

 

 

Hi.

It is not possible to have a dual diagnosis of AS and attachment disorder.The individual making the diagnosis is required to make a professional decision as to whether the difficulties observed are due to attachment disorder or AS but both are not allowed together.

 

D.The disorder is not attributable to other varieties of pervasive developmental disorder; schizotypal disorder (F21); simple schizophrenia (F20.6); reactive and disinhibited attachment disorder of childhood (F94.1 and .2); obsessional personality disorder (F60.5); obsessive-compulsive disorder (F42).

 

 

Karen.

Edited November 29, 2010 by Karen A

[Alma]

Thanks Karen, that's very interesting. We have a copy of a letter from Jack's psychiatrist to his GP stating the dual diagnosis and this has been discussed with various professionals without any queries. I'll raise a challenge and see where it gets us. From our point of view we are more interested in learning some srategies which may help J to cope with the challenges in his life and for us to be able function as a family.

[coolblue]

Hi.

It is not possible to have a dual diagnosis of AS and attachment disorder.The individual making the diagnosis is required to make a professional decision as to whether the difficulties observed are due to attachment disorder or AS but both are not allowed together.

 

 

 

Karen.

 

 

I don't think it means the two diagnoses are not 'allowed' to occur together, does it? Autism spectrum disorders are diagnosed by their symptoms. If someone's behavioural characteristics meet the criteria for a diagnosis of the autistic disorder AND those characteristics cannot be explained by the existence of the other conditions listed (or another list of chromosomal disorders) then a default diagnosis of AS or ASD or whatever, is made. This isn't a diagnosis in the sense that identifying a specific bacterial or viral infection is a diagnosis, it's a default diagnosis that says 'this person shows these behavioural characteristics but we can't identify a cause.' I can't see why someone couldn't show the symptoms of an ASD and an attachment disorder.

 

cb

[Karen A]

I don't think it means the two diagnoses are not 'allowed' to occur together, does it? Autism spectrum disorders are diagnosed by their symptoms. If someone's behavioural characteristics meet the criteria for a diagnosis of the autistic disorder AND those characteristics cannot be explained by the existence of the other conditions listed (or another list of chromosomal disorders) then a default diagnosis of AS or ASD or whatever, is made. This isn't a diagnosis in the sense that identifying a specific bacterial or viral infection is a diagnosis, it's a default diagnosis that says 'this person shows these behavioural characteristics but we can't identify a cause.' I can't see why someone couldn't show the symptoms of an ASD and an attachment disorder.

 

cb

 

From my earlier quote.

 

Quote

 

D.The disorder is not attributable to other varieties of pervasive developmental disorder; schizotypal disorder (F21); simple schizophrenia (F20.6); reactive and disinhibited attachment disorder of childhood (F94.1 and .2); obsessional personality disorder (F60.5); obsessive-compulsive disorder (F42).

 

 

 

 

 

See also the link re ICD 10 for AS which specifically states that Attachment disorder is excluded.

http://www.mentalhealth.com/icd/p22-ch07.html

 

 

A diagnosis of ASD can only be made where the behaviours observed are not attributable to .........

The above is taken directly from one of the recognised diagnostic criteria.

From personal experience CAMHS psychiatrists and psychotherapists spent three years debating about Ben and had to agree to differ because some thought attachment disorder and some thought AS.

 

There would in any case be little to be gained from a dual diagnosis of AS and attachment disorder because the accepted treatment offered by CAMHS for attachment disorder is not recognised as effective for AS.

 

The debate about AS or attachment disorder does crop up fairly frequently.However it is most often in the context of professionals wishing to attribute the behaviours observed to attachment difficulties [such as cold,unempathetic,anxious or depressed mothers] when parents feel there is no such history to cause such behaviours .

Edited November 30, 2010 by Karen A

[Karen A]

Alma I should say.

 

If you are hoping to obtain some provision from CAMHS on the basis of a diagnosis of Attachment disorder I can tell you about the provision Ben and ourselves obtained.He spent three years in weekly psychoanalytical psychotherapy.My husband and myself also spent three years in weekly psychanalytical psychotherapy to support Ben's work.He gained an awful lot from the work as did we.However it was the most difficult thing we ever did.Ben still has AS despite promises that after three years work he would no longer meet the diagnostic criteria. However I have not come across anyone else offered anything like that level of support.

 

Karen.

[coolblue]

Just trying to figure out, since there is general agreement that ASDs are organic in origin (genetically determined/physiologically mediated), what would happen in the case of a child who has the genetic basis for a diagnosis of an ASD, but also, due to upbringing, develops further problems with attachment? How could you separate the two? And how would you distinguish between a problem with attachment and an attachment 'disorder'?

 

cb

[oxgirl]

The debate about AS or attachment disorder does crop up fairly frequently.However it is most often in the context of professionals wishing to attribute the behaviours observed to attachment difficulties [such as cold,unempathetic,anxious or depressed mothers] when parents feel there is no such history to cause such behaviours .

 

So if a mother does have these problems and her son is dx as Asperger's, is it more likely to be Attachment Disorder?

 

~ Mel ~

[Karen A]

So if a mother does have these problems and her son is dx as Asperger's, is it more likely to be Attachment Disorder?

 

~ Mel ~

 

Sorry I did not explain very well.

There was a historical belief amongst some mental health professionals [most often psychiatrists and psychotherapists] that AS was not a developmental disorder.The theory was that it was a form of very early reaction to a mother that was either depressed or emotionally unavailable to her very young baby.Hence a type of what would now be called attachment disorder.

 

Most professionals recognise that AS is a developmental disorder.They do not give any credibility to the idea that it is anything to do with parenting.I think most parents here would find the idea fairly shocking.

 

However there are professionals who still tend to believe that where there are difficulties these are due to attachment disorder.Some are very highly regarded in the field of psychanalysis.In the vast majority of cases the Social History provides little evidence of a reason for attachment disorder.Most cases of attachment disorder that are diagnosed are amongst children who have a documented history of serious trauma,traumatic bereavement or loss.Most have been children who have been in the care of Social Services.There are a few other possible risk factors such as serious medical problems requiring traumatic intervention.

 

However in cases where there is a debate about attachment disorder or AS it can be difficult for professionals to decide.

 

In the first three years of Ben's life I suffered what would now be recognised as a nervous breakdown.I had a history of trauma which caught up with me when I found myself caring for two children under five.I never came to the attention of any services at the time.When Ben was about seven a teacher questioned whether Ben might have AS.At that stage I had obtained private psychotherapy and was coping much better.However on assessment CAMHS picked up on Ben's history of trauma due to my mental health difficulties. One psychiatrist thought AS and another thought attachment disorder.We were referred for psychotherapy on the basis that that would treat attachment disorder and Ben would be cured.

 

My husband and myself saw a psychotherapist every week for three years.Ben saw another psychotherapist.We spent much of the time going over my trauma in detail and much of the remainder of the time talking about the impact of my mental ill health on our marriage.

It was utterly traumatic at times and I tortured myself because I was told Ben who was having an awful time was in effect suffering because of me.

 

After three years some people still thought Ben had AS.He wanted to know himself.The psychotherapists suggested a 3di to prove that Ben did not have AS.However another CAMHS psychiatrist who was the expert in AS was in no doubt that Ben had AS after all.Despite all of the promises that if we worked hard enough Ben would be cured he still has significant Social Communication Difficulties.He works very well with adults who follow his agenda but has significant difficulties with his peers.CAMHS hardly spent any time working with school because they saw home as being at the root of the problem.Hence ASD outreach are now having to try to pick up that work.

 

I am only now nearly a year after finishing therapy starting to think about moving on.I am still very critical of myself having spent three years blaming myself.

 

Just trying to figure out, since there is general agreement that ASDs are organic in origin (genetically determined/physiologically mediated), what would happen in the case of a child who has the genetic basis for a diagnosis of an ASD, but also, due to upbringing, develops further problems with attachment? How could you separate the two? And how would you distinguish between a problem with attachment and an attachment 'disorder'?

 

[

 

In our case the professionals spent three years treating attachment disorder.The treatment should have cured attachment disorder.When they decided the child was cured they organised further tests which showed that the child was not cured because they had AS.

 

Offering a trial of psychotherapy might be one way to find out in debatable cases.Psychotherapy is not supposed to be effective in AS so in theory the fact that it works would show that a child has attachment disorder.However that is not going to happen because psychotherapy is extremely expensive and is being cut back in the current climate.In any case although Ben was not supposed to be helped by psychotherapy he certainly benefited from it and in the same situation I would probably accept the offer of psychotherapy again.

 

Attachment disorder is in psychiatric terms a specific diagnosis.It is not usually related to upbringing.It relates to trauma in the first three years...some might say even the first two years of a child's life before the development of speech.

Some professionals now recognise that difficulties with attachment can arise where there is a significant traumatic loss later in life [in my case at age 9].However this is not recognised as attachment disorder as such.

 

A problem with attachment is not a diagnosis but a general description.It could be argued that children with ASD have problems with attachment because of Social Communication Difficulties.This is why a full history of development and Social Factors is significant.

 

A significant proportion of the population would according to assessments of patterns of attachment be found to not have a secure pattern of attachment including many very driven high acievers.However their pattern of attachment may not be a problem for them.

 

Things become more complicated regarding the organic nature of AS versus attachment disorder.Some professionals would argue that very early experiences have an effect on the developing brain and si is also organic at some level.I know the psychiatrist who assessed Ben believes that in a few years there will be a genetic test for AS and that will end the debate.However the psychotherapists do not agree.

 

In our case the psychotherapists were still in denial about the AS diagnosis even when Ben was discharged despite having to admit that ASD outreach might be helpful.

 

If a child with a diagnosis of AS develops difficulties later in life because of a traumatic event or loss then the history would usually show that this was not attachment disorder.In an ideal world support should then be offered which is appropriate to the child having a previous AS diagnosis.However this may be difficult to obtain in practice.Some professionals believe that any difficulties that a child with AS has are purely related to AS and would therefore not look at other issues in a child's life.There is unfortunately very little CAMHS input available for most children with a diagnosis of AS regardless of any other difficulties in their lives.Furthermore in my experience there is little knowledge of AS amongst some CAMHS professionals.There can be a tendency to view what many would consider to be features of AS as symptoms of mental ill health.

 

So if a mother does have these problems and her son is dx as Asperger's, is it more likely to be Attachment Disorder?

 

 

Mel.To answer your question more briefly.I think the vast majority of people here on the Forum would find the idea that because a child with AS happens to have a mother with problems it is more likely to be attachment disorder pretty shocking.

 

In any case by the time many parents of children with AS have battled with the system to try and obtain support for a child with possible AS they will probably have mental health problems if they didn't before. However there are still some professionals who are rather obsessed with mothers and would go as far as to suggest they are the cause of all cases of ASD.

 

If you are asking the question because you are wondering then please do not worry too much.Attachment disorder does not happen in the vast majority of cases where mums have problems.The majority of cases of children with attachment disorder are where children have been taken into care.I was a bit of an unusual situation.

 

Sorry to the OP that this is so long and a bit off topic.However my earlier comments might have been confusing.Who is to say whether these are any better because I am still working it out.

 

Karen.

Edited December 1, 2010 by Karen A

[Karen A]

Thanks Karen, that's very interesting. We have a copy of a letter from Jack's psychiatrist to his GP stating the dual diagnosis and this has been discussed with various professionals without any queries. I'll raise a challenge and see where it gets us. From our point of view we are more interested in learning some srategies which may help J to cope with the challenges in his life and for us to be able function as a family.

 

If you are looking for some information on strategies for helping children with attachment disorder I can recommend ''Inside I'm Hurting'' [practical strategies for supporting children with attachment difficulties in schools] by Louise Michelle Bomber published by Worth Publishing.It includes lots of ideas.Although it relates to Attachment Disorder it also suggests that many of the strategies recommended for pupils with ASD are similar and would be appropriate.Eg Social Stories,clear visual timetables,

 

Karen.

Edited December 1, 2010 by Karen A

[Alma]

Thanks Everyone for your input. You've certainly given me some things to think about. We are currently working towards some support from a local organisation who help autistic youngsters in mainstream education and we're due to meet them along with someone from CAMHS soon. I'll raise some of your points and see how we go on.

 

On a lighter note, at the weekend I bumped into a Mum who I met on a parenting Aspergers workshop earlier this year - We're getting together next week to have a coffee and a chat. I think It will do us both good and I'm going to let her know about this forum.