Short exchange with Dr. Richard Solomon

Dr. Rick,
A few days ago I was reviewing a web presentation on attachment. Nothing new but a nice refresher. This morning I was reviewing a comprehensive assessment on a child diagnosed with PDD NOS. I was also thinking about some thoughts a co-worker had recently shared, about co-occurring dd and cmh disabilities and it struck me that the diagnosis of autism or something in the spectrum almost requires an attachment issue. I also thought about the LOVAAS approach and autism treatment in the clinical or community setting with non family members who sometimes change frequently. Where there has been some corroboration of positive outcomes with LOVAAS in IQ, those positive outcomes have not generally included behavior. The best overall outcomes must include family participation and even LOVAAS/ABA has now acknowledged the importance of joint attention. Yesterday I also read an article about the longing that many if not most children in the spectrum have, in spite of inappropriate or ineffectual attempts, for relationships. (Hope that wasn't too long of a segue.)
If most children with autism also have attachment issues, is center based or even community based treatment ultimately counter productive for the overall and long term benefit of the child and family? From a mental health perspective you would NEVER prescribe a child with an attachment disorder, especially a young one, with 30, 20, or even 10 hours per week in a center or community setting with strangers and without a family or caregiver present. That would be almost unfathomable.
Your thoughts, please?
Pete

Hi Pete,I fully agree. Drilling a young child 30-40 hours per week is developmentally inappropriate and can interfere with multiple developmental processes including attachment, affect, initiation, and autonomy. ABA is good for cognitive gains but depends on naturalistic settings for generalization and attainment of true social abilities. The fundamental relationship in ABA type interventions is: 'Do this. Good job' which is a very impoverished form of relationship. The adult leads. Child led interventions promote affect, initiation and autonomy--three very high values for me. Joint attention is just the beginning. I'm afraid we've let the tail wag the dog. By using empirical approaches only without a respect for what we know to be developmentally necessary, we've been able to teach discrete skills at the cost of developmental integrity. You can quote me on this. Hope this helps.Take care,
Rick
Richard Solomon
MDMedical Director
Ann Arbor Center for Developmentaland Behavioral Pediatrics

Added note from Pete: This does not mean that children with Autism have an attachment disorder. Children with Autism generally do develop strong attachments: however it is often an irregular and sometimes difficult attachment. The developmental needs of the child as well as the relationship and what is called "joint attention" are central to the needs of the child and family.

Why spend additional time and money on planning if it takes away from service or project hours?

Imagine you were going to Mars. (There is some current debate in the United States about a new goal for the space program, to go to Mars and perhaps place a permanent settlement there.)Now imagine you are one of the potential astronauts. You are in a first stage promotional meeting and the director of NASA says: “we’re not going to spend a lot of time planning; but we’ll make it up with close contact during the trip. This is pretty big so we won’t have time for people to review and talk about all of the components. Don’t worry though; we have some great people working on this. Some of the traditional experts for this sort of thing may not be involved; but, that’s ok, we’re sure we won’t need them. We’re pretty sure it will all fit together and there won’t be any negative consequences. This is exciting. It’s going to be great!”Now the director looks at all the astronauts and asks: “So who will be the first to go to Mars?” Would you volunteer?In the case of a trip to Mars, hopefully NASA would not need to make such a choice, but in other situations this choice is presented. Most of the time it is a red herring. A false argument. More treatment does not always mean better outcomes and at a certain point, it never means better outcomes. If though, there really had to be a choice, I would always choose thorough (not over) planning, even if it meant just a little less in the way of services or project time.

The Quest for Quality, is it still important in an upside down economy and chaotic society?

Life, plus economic worries, time constraints, conflicting information and the pull of multiple demands can certainly cause anxiety, adding a child with autism or behavioral problems can seem almost impossibly and absolutely overwhelming.
There is an old adage that goes something like: 'when you're up to your neck in alligators it is difficult to remember that your original intention was to drain the swamp.' I like this adage because draining the swamp would take care of the problem with the alligators and a whole bunch of other potentially serious but not as seemingly urgent problems, such as mosquitoes.
That's sometimes how it is with children's treatment. The immediate relief of your stress and more treatment seems to be the best cure for what ails you and our child. Unfortunately this is not always the case. The right intervention is always more important than the most intervention. Years ago my wife and I owned a Ford Escort. All in all it was a good car. We kept having an electrical problem though and kept having to take it back to the dealer. After many trips, a mechanic discovered that we kept a spare set of keys in the ash tray. (Seemed logical to us.) Those keys would move around as the car was moving and eventually would make a connection and cause a short. Once the keys were removed, we had no more electrical problems with the car.
When you are looking for the right treatment for your child, more is rarely better, especially when it is in a contrived environment or primarily with the therapist. Remember to look for quality above quantity.