AN INVESTIGATION INTO THE DIFFERENTIAL DIAGNOSIS OF AUTISM SPECTRUM DISORDER AND ATTACHMENT DIFFICULTIES by ROWAN KENDALL-JONES A thesis submitted to the University of Birmingham for the degree of DOCTOR OF APPLIED EDUCATIONAL AND CHILD PSYCHOLOGY School of Education University of Birmingham Edgbaston Birmingham B15 2TT University of Birmingham Research Archive e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder. ABSTRACT This study reviews the evidence for commonalities in the behavioural presentation and areas of compromised functioning in children with Autism Spectrum Disorder (ASD) and attachment difficulties. Confusing ASD and attachment difficulties has far-reaching implications in terms of access to services and interventions, family dynamics and life opportunities. A comparative analysis was conducted to evaluate current practice, assess the scale of misdiagnosis, and identify areas of differential presentation which may facilitate accurate diagnosis. Teacher- ratings of the frequency of behaviours drawn from ‘The Coventry Grid: ASD vs. Attachment Problems’ (Moran, 2010) were collected for two groups of primary school children matched for age, sex and school: one with recent diagnoses of ASD (n = 12) and a control group with no diagnoses (n = 12). Three children with ASD diagnoses had higher ratings for attachment difficulties than ASD, at a level approaching significance. However, a within-group analysis showed no significant difference between the median ASD and attachment difficulties ratings in the group with an ASD diagnosis. Further, a between-group comparison revealed significantly more behaviour suggestive of attachment difficulties in the ASD group than exhibited by the control. Finally, the data were used to examine the measure, based on ‘The Coventry Grid’ (Moran, 2010). It was found to have an acceptable level of reliability and good face and content validity. However, while the literature suggested good construct validity, analysis of dimensionality raised questions about how we construe the aetiology and mechanisms that constitute the phenomenology that informs the diagnosis of ASD and attachment difficulties. The findings have significant implications for the ASD diagnostic process, in terms of the data collected and the professionals involved. I would like to thank Alan Toms and my supervisors, Huw Williams and Sue Morris, for their continued support throughout this long process. CONTENTS PAGE Page CHAPTER 1 INTRODUCTION ........................................................................................................ 1 1.1 Background ..................................................................................................................... 1 1.2 Problem Statement .......................................................................................................... 2 1.3 Professional Significance ................................................................................................. 3 1.4 Terminology .................................................................................................................... 4 1.4.1 Definition Key Terms – Autism Spectrum Disorder (ASD) ........................................... 4 1.4.2 Terminology Used Within This Study ............................................................................ 6 1.4.3 Definition Key Terms - Attachment ............................................................................... 7 1.4.4 Attachment Difficulties ................................................................................................. 10 1.4.5 Attachment Terminology Used Within This Study ...................................................... 11 1.5 Diagnosis ........................................................................................................................ 11 1.5.1 Diagnosis – ASD: ICD ................................................................................................... 12 1.5.2 ASD: DSM ..................................................................................................................... 13 1.5.3 Attachment Difficulties: ICD ........................................................................................ 13 1.5.4 Attachment: DSM ......................................................................................................... 15 1.5.5 The Validity and Reliability of Diagnoses .................................................................... 15 1.6 Aims of This Study ........................................................................................................ 17 1.6.1 Overview of Thesis Structure and Content .................................................................. 17 CHAPTER 2 LITERATURE REVIEW .......................................................................................... 19 2.1 Aetiology ........................................................................................................................ 19 2.1.1 Aetiology of ASD ........................................................................................................... 20 2.1.2 Aetiology of Attachment Difficulties ............................................................................. 21 2.2 Risk Factors for ASD and Attachment Difficulties ...................................................... 22 2.2.1 Perinatal Risk Factors ................................................................................................... 22 2.2.2 Sex .................................................................................................................................. 23 2.2.3 Socioeconomic Status (SES) .......................................................................................... 24 2.2.4 Maternal Age ................................................................................................................. 26 2.2.5 Parental Education ........................................................................................................ 27 2.2.6 Proximity of another Child with ASD .......................................................................... 27 2.2.7 Maltreatment ................................................................................................................. 28 2.2.8 Summary of Commonalities and Differences in Risk Factors ..................................... 29 2.3 Brain Mechanisms and Structure ................................................................................. 30 2.3.1 Amygdala ....................................................................................................................... 30 2.3.2 Executive Function (EF) ............................................................................................... 33 2.3.3 Theory of Mind (ToM) .................................................................................................. 39 2.3.4 Summary of Commonalities and Differences in Brain Mechanisms and Structure.... 43 2.4 Behavioural Presentation .............................................................................................. 44 2.4.1 Triad of Impairments .................................................................................................... 44 2.4.2 Extreme Deprivation and ASD ..................................................................................... 46 2.4.3 RAD and ASD ............................................................................................................... 47 2.4.4 Attachment Difficulties, Less Extreme Deprivation and ASD ..................................... 48 2.5 Differential Diagnosis .................................................................................................... 48 2.6 UK Diagnostic Practice ................................................................................................. 51 2.6.1 Local Diagnostic Practice .............................................................................................. 54 2.7 This Study ...................................................................................................................... 55 CHAPTER 3 METHODOLOGY ..................................................................................................... 57 3.1. Overview ........................................................................................................................ 57 3.2 General Perspective ....................................................................................................... 58 3.3 The Research Context ................................................................................................... 60 3.4 Design ............................................................................................................................ 62 3.5 Measure ......................................................................................................................... 63 3.5.1 Validity of the Measure ................................................................................................. 65 3.5.1 (i)