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LD&Autism

Ben Grey and Juliet Kesteven have considerable experience in the assessment of parents with a learning difficulty, this being a significant part of the service offered at Family Care previously, and now of the work carried out by Cambridge Centre for Attachment. Juliet Kesteven is trained in the use of the Parent Assessment Manual Software (PAMS), and PAMS assessments are available upon request. We are also able to offer cognitive assessments carried out by an associated clinical psychologist, but fully integrated into our wider assessment of attachment and parenting.

“The Insidious Legacy of Childhood Trauma”

Considerable research both in relation to parenting and to child development suggest that the way parents think is a more critical indicator as to the risks or potential in child development than the specific things parents do (Reder and Duncan 1999, Slade 2005, Fonagy 2006). The problem of assessments which focus primarily on task-based observation of parenting skills in cases of child maltreatment, or significant failures in parenting, is that parents fail in parenting less because they do not know what they should be doing, but more because they do not understand how generalised parenting ‘knowledge’ relates to the specific child in front of them. Parents who have had adverse childhood experiences, which remain unresolved, frequently distort the meaning of their own and their child’s experience in ways that are self-protective and relate to their own experiences of danger and threat, and are not protective to their child (Crittenden 2008). This ties in with the findings of Professor Sue McGaw and her colleagues that it is childhood trauma, not possessing a learning difficulty per se, that results in dangerous parenting:

‘Parent childhood trauma presented as an insidious legacy and a dominant factor impacting the functioning of many parents with [learning difficulties] in this study and ultimately, the quality of their parenting.’

From “Predicting the unpredictable? Identifying high-risk versus low-risk parents with intellectual disabilities” Sue McGaw,, Tamara Scully, Colin Pritchard (2010), Child Abuse & Neglect 34 (2010) 699–710

Assessing the Impact of Trauma in Parents with Learning Difficulties

It follows from this that it is of critical importance in the assessment of high-risk parents (or those thought to potentially pose a significant risk to their children), who may also have learning difficulties, to examine and assess childhood trauma and its impact on parenting. It is the emotional and psychological impact of experiences of trauma that may influence how a parent perceives their child, rather than the parents’ learning difficulty. If this is the ‘dominant factor impacting on functioning’ of the parent with learning difficulty (and indeed many parents who do not have a learning difficulties), then assessing the impact of past experiences of trauma and loss should be a central part of the assessment process, otherwise the most central and pertinent issues are being overlooked.

The assessment methods used by Cambridge Centre for Attachment, which examine the impact of childhood trauma and experiences of danger or threat on adult functioning and parenting, are therefore particularly suited to the assessment of parents with learning difficulties thought to pose a risk to their child(ren). The Adult Attachment Interview (AAI) not only identifies experiences of childhood trauma but is also able to assess whether such past traumatic experiences or losses remain ‘unresolved’ in the mind of the adult, and so continue to impact upon their current functioning. The AAI also identifies the relationship patterns and habits of thinking and feeling that have arisen as a result of past experiences. More positively, the interview may also draw attention to the process by which an adult may have learned from their past and reorganised their life in ways that are beneficial to them and their dependent children. The AAI has been validated and used successfully in research with parents who have a learning difficulty.

The Parent Development Interview (PDI) helps identify whether, and potentially how, such adverse experiences may have distorted the way in which the parent perceives their child. The interview examines the parents’ ability to understand and respond to their child’s needs, and the nature (including risk) of their relationships that either support or hinders their parenting. When these are seriously problematic, parent education work, or skills training, is unlikely to be successful (and may in fact be harmful) because the parent will incorrectly ‘read’ (give meaning to) the child’s experience, and so mis-apply whatever they have learned.

The attachment interviews, therefore, are powerful in formally assessing whether and how past traumatic experiences may have impacted upon current parenting in parents with learning difficulties. Whilst it is true that these tools are verbal, attachment assessments have been used with children from the age of 3 upwards, so whilst some verbal competence is needed, normative adult verbal reasoning is not. The nature of the assessment procedures in fact also offers several advantages in assessing parents who may have difficulties in verbal understanding or in making themselves understood. The attachment interviews are transcribed verbatim, which means that it is possible to check for misunderstandings in communication. In addition, the assessment procedures look for patterns that are communicated in diverse ways, some consciously and some unconsciously, which means that conclusions derived from different aspects of the interview can be ‘tested’ out by other aspects that would not be affected by a learning difficulty, or affected in the same way.

Embodied thinking and Instinctive Understanding

It is important to stress that whilst some of the literature surrounding adult and child attachment and reflective functioning is complex, what is being sought from parents is not. Many parents with identified learning difficulties are more than able to demonstrate the ability to ‘understand’ their child’s behaviour, thinking and feeling, and respond appropriately. It is not sophisticated or abstract thinking that is required, but rather thinking that is not distorted by the adults’ need to protect themselves or elicit support from others, in ways that might be dangerous to parenting and in other close relationships. Our own long-standing experience, together with the research, attests to the fact that many parents with learning difficulties have warm empathetic relationships with their children, whom they know and are able to understand well or well enough. The distortions that interfere with this, in the functioning of some parents, are not the result of a learning difficulty alone.

Importantly, the attachment assessments also allow information derived verbally from interviews such as the AAI and PDI to be compared with that which is visible in ‘non verbal’ observations of parent-child interaction such as the CARE-Index. The CARE-Index examines the connection between a parent and their infant from careful and detailed analysis of short video clips of play. It is possible to ‘see’ whether the concerns identified in the interviews with parents are enacted in face-to-face interaction or whether a warmer, more positive relationship is observed. We are also able, where relevant, to use picture cards and other imaged tools to access a parents’ imaged memory directly, and thereby ensure further validity of the opinions derived from our assessments.

Autism, Autistic Spectrum Disorders and Attachment Assessments

Since the Strange Situation Procedure (SSP) was developed to differentiate attachment patterns, there have been a number of studies exploring the attachments of children with autistic spectrum disorders (ASDs) in a more systematic way. These have established clearly that autism is a separate concept from attachment, and that attachments of children with autism can be assessed in a similar way to children without an ASD diagnosis. A recent summary states:

‘A series of studies demonstrated that children with autism showed active preferences for their caregivers over a stranger, and that they were distressed by separations from the caregiver and sought proximity when they were reunited. Sometimes things were done in atypical ways, and sometimes unusual behaviour was observed that appeared to be unrelated to attachment, but it seemed to have been demonstrated conclusively that some children with autism were capable of demonstrating secure attachment’

Taylor E, Target M, and Carman T (2008) “Attachment in adults with High Functioning Autism”, Attachment and Human Development, Vol. 10, No 2, June 2008, pp 143-163

Whereas the Strange Situation (and video-taped procedures such as the CARE-Index, described below, which were derived from it) assess attachment through observed interaction, the Adult Attachment Interview (and interviews such as the Parent Development Interview, PDI, which are derived from it) uses discourse, which would be thought to present particular problems for adults with ASD. In particular the idea of reflective functioning (understanding the behaviour of oneself and others in terms of mental states, see also below in relation to the PDI) would seem to be similar, if not identical, to the concept of ‘theory of mind’, which is thought to be lacking or impaired in adults and children with ASD.

However, although the research here is more limited, high functioning adults with ASD could engage with the AAI, could be classified as securely attached and patterns of attachment could be differentiated according to the interviews procedure for classification. It was clear that the AAI does activate and assess the attachment system of adults with ASD, although aspects of the responses of the adults may be more related to their general discourse style (and autism) rather than attachment status. It was interesting to note that Reflective Functioning scores (see below in relation to the PDI) were not particularly well related to the methods developed to assess ‘Theory of Mind’ in autistic adults. This is thought to suggest that some, if not all, of the adults with ASD may, as they develop, find a way around their impairment (or a way of compensating for it) in relation to their closest relationships (which are assessed in the AAI/PDI), which may not be apparent in their wider functioning.

Overall the research would suggest that the attachment procedures offer valid and important information in the assessment of both adults and children with ASD, although caution is needed as the concepts to not entirely ‘map’ (they have a different theoretical basis) and also some of the methods needed to assess attachment may be accessed / approached differently by adults and children who have ASD.

Conclusions

In summary, research into the impact of learning difficulties upon attachment and parenting would suggest that whilst learning difficulties may have an effect upon aspects of parenting, the psychological and emotional effects of dangerous and traumatic childhood experiences are more likely to be the dominant factor in high risk parenting. The assessment methods of Cambridge Centre for Attachment assess these issues directly, and so are not only valid with parents and children who have a learning difficulty, but are of critical importance in directing attention to the most salient issues. Whilst interview based methods require caution in some cases, again, the requirement for evidence for varied and differing sources help ensure that the assessments, and the conclusions derived from them remain valid. Our own long-standing experience, together with the research, attests to the fact that many parents with learning difficulties have warm empathetic relationships with their children, whom they know well, and are able to demonstrate this in attachment interviews. In some cases however, past experiences distort the way in which an adult perceives their child, and relates to him or her, in ways that can prove dangerous for parenting. The expertise and tools used by Cambridge Centre for Attachment can help identify these in ways that can inform decision-making and direct intervention by drawing attention to the most important issues.