As child therapists we are often expected to have a myriad of knowledge and skills about so many client presentations, symptoms, disorders, the list is endless! However, if your initial child/play therapy focused on experiential learning, foundational knowledge may be somewhat rudimentary when working with, conceptualising, and evaluating clinical work, especially with those children who have attachment difficulties and/or autism.
Often, the referral to work with the child is too broad, generalised, or limited, with practitioners finding themselves in a situation where the child may be on the autistic spectrum, may have attachment difficulties or have both.
How many times has this happened to you, and how difficult is it to differentiate between what behaviours may be ‘attachment-related’ or those that may be ‘autism-related’?
Having a good understanding of Attachment Theory could be considered one of the fundamental areas of knowledge necessary for child therapists when working with children and young people. Similarly, understanding of Autism and how this can impact on the development on the child’s attachment style is important as it can be confusing, especially as both relate to disruptions in the parent/caregiver-infant bond and connection.
There can be a complex overlap between attachment and autism especially in relation to communication and socialising, both of which can impact on each other. Furthermore, they can equally result in challenges with sensory processing, theory of mind and how children respond to their parents and caregivers.
For many therapists, consideration of a client’s attachment styles and strategies is an important factor in intake meetings, case conceptualisation and ongoing work. It is important to note, that evidence suggests that children with autism can and do develop attachment.
In 2010, Psychologist Helen Moran and a team at Coventry and Warwickshire Partnership Trust developed a framework called the Coventry Grid out of concern that children were being misdiagnosed with autism. It was designed to differentiate between the behaviour of children with Autistic Spectrum Disorder (ASD) and those with significant attachment difficulties. It was revised in 2017 to incorporate Pathological Demand Avoidance (PDA).
The Coventry Grid has three columns:
1. Column One: Presents an area of behaviour
2. Column Two: How a child with ASD might present in response to the behaviour
3. Column Three: Details how a child with attachment problems may present
Designed so that a direct comparison can be made, practitioners simply highlight or mark next to any statement that applies to the child. Once completed, consideration can be given as to whether more statements apply to ASD or Attachment difficulties.
The purpose of the framework is to support clinicians to be able to differentiate between the behaviour of children with ASD and those with significant attachment problems. For clients who have come from a background of developmental and/or relational trauma (in particular, those who are fostered or adopted), it may be particularly challenging to get a definitive assessment as to whether they have difficulties with attachment, or autism, or both.
As child therapist we do not diagnose or assess clients unless trained to do so. Whilst it needs to be stressed that the Coventry Grid was not designed to be a stand-alone diagnostic tool and should never be used as such, it can be a very valuable resource if applied during case conceptualisation, in consultation with professionals and whilst supporting parents/carers who are in the process of understanding the causes of their child(s) behaviour and relational responses.
Currently, it is one of the most effective tools for practitioners to start formulating whether to offer more structured or unstructured responses as-well as which parts of the creative toolkit may be more appropriate to support the client.
Fortunately for practitioners, the Coventry Grid is freely available for use on her website: https://drawingtheidealself.co.uk/the-coventry-grid.
(Authors: Karen O’Neill & Tara McDonald)
Published and Copyrighted by PIP Solutions: 10th September 2023
Coughlan, B. (2018), Autism and Attachment: A Need for Conceptual Clarity https://www.acamh.org/blog/autism-attachment-conceptual-clarity/
Davidson, C., Moran, H., & Minnis, H. (2022). Autism and attachment disorders – how do we tell the difference? BJPsych Advances, 28(6), 371-380. doi:10.1192/bja.2022.2
Giannotti, M & de Falso, S (2021) Attachment and Autism Spectrum Disorder (Without Intellectual Disability) During Middle Childhood: In Search of the Missing Piece, Department of Psychology and Cognitive Sciences, University of Trento, Rovereto, Italy
Hunt, K & Rodwell, H (2019) An Introduction to Autism for Adoptive and Foster Families, Jessica Kingsley Publishers