A Comparative Study of Attachment Behavior in Young Children with Autism or Other Psychiatric Disorders

A Comparative Study of Attachment Behavior in Young Children with Autism or Other Psychiatric Disorders SALLY J. ROGERS, PH.D., SALLY OZONOFF, M.A.,

AND

CHRISTINE MASLIN-COLE , PH.D .

Abstract. The present study examined attachment behavior in children with autism and children with other developm ental or psychiatri c disorders. The groups were matched on chron ological and mental age , lQ , and socioeconomic status. When a modified Strange Situation paradigm was used, no group differences were found in proximity seekin g, contact maintenance , proximity avoidance, or contact resist ance ; the group s also did not differ in their overall sec urity ratings . Attachment security was related to several developmental variables in the autistic group but not in the nonauti stic comp arison group . Thi s suggests that attachment formation may involve different processes in autistic children than in nonautistic children of equivalent intellectual level. J . Am . Acad. Child Adolesc , Psychiatry, 1991, 30, 3:483-488. Key Words: autism, attachment, pervasive developmental disorder.

Research on early social relationships has been profoundly influenced by Bowlby's clinical descriptions and theoretical formulations (Bowlby, 1958, 1969) and Ainsworth' s devel opment of a standard paradigm for studying attachment behavior (Ainsworth et aI., 1978). The Strange Situation paradigm has been used to study the attachment behavior of both normally developing infants and young children and those with various developmental impairments. Studie s of young children with Down' s syndrome (Blacher and Meyers , 1983) , prematurity (Easterbrooks, 1989), neurological and motor impairments (Stahlecker and Cohen, 1985), and physical and cosmetic handicaps (Wasserman, 1986) have reported fairly normal distributions of infants among attachment security categories . In the past few years, studies of the attachment behavior of young children with autism have appeared in the literature . Although autism has been conceptualized as a disorder of attachment by some (Mahler, 1952), the results of recent investigations have demonstrated that there is evidence of attachment security in young autistic subjects and that the attachment behavior of autistic children closely resembles that of mentally retarded and language delay ed clinical comparison group s (Sigman and Ungerer, 1984; Shapiro et aI., 1987; Sigman and Mundy, 1989) . While these studies begin to answer questions about the attachment security of autistic children, various methodological issues have complicated interpretation. It is difficult to comp are the findings of Sigman and colle agues (Sigman Accepted December 10, 1990. Dr. Rogers is all Associate Professor ofPsychiatry at the University of Colorado Health Sciences Center, Ms. Ozonoff is a doctoral candidate in the Department of Psychology at the University of Den ver, and Dr. Muslin-Cole is an Assistant Professor in the Department of Human Developm ent and Family Studies at Colorado State University. This research was support ed in part by Grant #G008100247 to Dr . Rogersfrom the Office of Special Education and Rehabilitation, U.S. Dept. of Education . Reprint requests to Dr . Rogers, University of Colorado Health Sciences Center , Davis Pavilion , Box AOII-12, 700 Delaware , Denver, CO 80204 . 0890- 8567/91/3003 -0483$03 .0010© 1991 by the American Academ y of Child and Adolescent Psychiatry .

J . Am.Acad. Child Adolesc. Psychiatry, 30:3 , May 1991

and Ungerer, 1984; Sigman and Mundy, 1989) with studies of other clinical groups because a discrete behavioral coding system was used (e.g. , behavioral frequencies rather than global ratings of security). Also, the comparison groups used in the Shapiro et al. (1987) study were not matched with autistic subjects on chronological age, developmental level, or language level, making it difficult to draw firm conclusions about the similarities and differences in attachment behavior among the different groups. The present investigation extended the comparative study of attachment behavior in young autistic children by making two methodological modifications: first, global ratings of attachment security were used, and second, comparison subjects were carefully matched with autistic subjects on several developmental and demographic variables. As Sigman (1989) has pointed out, choosing an appropriate comparison group when studying autism is a complex task . Young autistic children are multiply handicapped; they have significant impairments in cognitive, language, social, and behavioral development. Thus, in the present study, young autistic subjects were matched to a comparison group of psychiatrically and intellectually impaired, but nonautistic, subjects . The comparison group had intellectual handicaps similar in severity to those of the autistic group. However, they had no autistic-like deficits in social relatedness, demonstrating social interest, social reciprocity, social initiative, social play , and interest in peers. The following hypotheses were generated for this study: I . The autistic subjects, because of their profound social impairments , would demon strate significantly greater

levels of insecurity than the comparison group. 2. Both groups of subjects, because of their psychiatric symptomatology, would demonstrate predominantly insecure behavior in the Strange Situation. 3. Based on the results of a preliminary study (Rogers et aI., 1990, unpublished manuscript), the authors predicted that attachment security and severity of developmental handicap would be related in the autistic group ; they did not expect a relationship between these variables in the nonautistic comparison group.

483

ROGERS ET AL.

Met hod Subjects

Over a 9-year period, data were collected on 60 children referred to a therapeutic treatment program that has been previously described in the literature (Rogers, et al., 1986; Rogers and Lewis, 1989). All children received psycholog ical, speech and language, and developmental evaluations from a diagnostic team consisting of a child clinical psychologist , speech and language pathologist, early childhood special educator, and physical or occupational therapist. Psychiatric diagnoses were made using DSM-Ill from 1981 until 1987, and with DSM-IIl-R from 1988 to the present. Consensus on diagnoses was reached by at least two separate psychologists or psychiatrists on the diagnostic team who were experienced in psychiatric diagnosis of young children . It was decided to combine subjects with infantile autism (IA) (N = 11) and those with pervasive developmental disorder (PDD) (N = 6) for several reasons. First, previous comparisons of these subjects have indicated no differences in IQ or socioeconomic status (SES), two of the most powerful predictors of children's functioning (Rogers and Lewis, 1989; Rogers and DiLalla, 1990), although in these previous studies, the PDD group has demonstrated better functioning in most developmental domains . Second, a main difference between the two diagnoses in DSM-III concerned age of onset , which is not a variable of interest in this study and has not been shown to be associated with other differences in children with these two diagnoses in previous work (Rogers and DiLalla, 1990). Another main difference between these two groups relates to severity of autistic symptoma tology, which is reflected in the Childhood Autism Rating Scale scores . Third, several papers have documented the relative lack of behavioral different iat ion between young

children diagnosed as IA and those diagnosed as PDD (Fein, et al., 1985; Dahl et al., 1986; Rescorla , 1986). Finally, with the advent of DSM-III-R and its broadened definition of autistic syndrome, virtually all of these children would be assigned that diagnosis . Seventeen subjects with autistic syndrome or other pervasive developmental disorder were matched with 17 children with other psychiatric diagnoses, including reactive attachment disorder, oppositio nal disorder, mental retardation , and adjustment disorder . All the children in the nonautistic group exhibited cognitive and language delays in addition to their psychiatric disturbances, as can be seen by their scores on the developmental profiles (Table I). Descriptive characteristics of the sample are presented in Table I . Measures

IQ and MA . Intelligence quotie nts (IQ) and mental ages (MA) were assessed at the time of diagnosis . Because of the appeal of the Merrill-Palmer Test of Mental Abilities (Stutsman , 1948) to these subjects and the wide range of mental ages (from approximately 18 months to 60 months) that it can assess , Merrill-Palmer scores were used whenever a basal and ceiling were attained . The majority of subjects' mental age scores used in this study came from the Merrill -

484

I . Description and Comparisons of the Two Groups of Subjects by Chronological Age (CA), Mental Age (MA ), IQ, Childhood Autism Rating Scale (CARS) , Socioeconomic Status (S£S), Sex, Race, alld Developmental Profile Levels of Cognition (COG) , Language (LAN), Gross Motor (GMOT) Fine Motor (FMOT), Self-Help (SH), and Social (SOC) Skills. TABLE

Nonautistic Group

X CA MA IQ CARS SES Sex (M:F) Race (maj: min) Profile COG Profile LAN Profile GMOT Profile FMOT Profile SH Profile SOC

SD

50.8 11.0 43.4 14.3 84.8 20.1 22.8 8.0 2.1 1.5 16:1 13:4 40.4 11.6 37.4 17.8 45.9 18.1 44.3 12.0 39.9 18.0 42.9 11.5

Autistic Group

X

SD

47.6 10.2 39.1 10.0 82.7 18.1 34.9 6.5 2.7 1.0 14:3 9:8 27.1 9.0 24.6 12.9 37.7 11.6 34.5 11.0 32.3 11.8 31.4 13.1

t(32)

0.86 -1.00 -0.32 4.58 *** 1.43

-3.49** -2.18* -1.46 -2 .31* -1.24 -2 .55*

*p :5:0.05, **p :5:0.01, ***p :5: 0.001.

Palmer. For those children who did not attain a basal or ceiling score on the Merrill-Palmer, the Leiter International Performance Scale (Leiter , 1979) was used as the second choice. While the authors are not aware of formal studies comparing results from these two tests , the authors' clinical experience has been that of general concurrence of scores from these two tests. For lower functioning or younger children who could not attain basal scores on either of those tests, the Mental Scale of the Bayley Scales of Infant Development (Bayley , 1969) was used . Since the Merrill-

Palmer and Leiter tests both assign a ratio IQ score, a ratio 1Q was also calculated from the Bayley by determining the developmental age equiva lent of the raw score (the MA) and dividing by chronological age (CA). While standard procedures for administering and scoring each item were observed, optimal performance was sought by testing subjects in several short sessions and occasionally using material rewards in addition to social praise . Table I contains mean IQ and MA scores for the two groups . The IQ of the autistic group in this study is higher than the mean IQ of the whole group of autistic/PD D subjects from which these 17 subjects were drawn because of the desire to match them on IQ, MA, and CA with the comparison group . Early Intervention Developmental Profile and Preschool P rof il e (Schafer and Moersch, 1981). The profiles assess development in six domains : cognition , language, perceptual-fine motor, gross motor, social-emotional, and selfcare . Administration and scoring were carried out according to standard instructions by a special educator, speech and language therapist, and occupational therapist who were naive to the formal psychiatric diagnoses of subjects and hypotheses of the study . For each of the six domains, a developmental age in months was calculated based on the number of items passed . See Table I for mean developmental profile scores for the two groups. J . Am. Acad. Child Adolesc. Psychiatry, 30:3, May 199 J

ATIACHMENT COMPARISON

Childhood Autism Rating Scale (CARS) (Schopler et aI., 1980) . The CARS rates behavior on 14 subsca1es, including impairment in social relationships, imitation deficits, inappropria te affect , bizarre body use , peculiarities in handling objects , resistance to change, abnormalities in visual, auditory, and near-receptor responsive ness, anxiety, abnormal verbal and nonverbal communication, activi ty level, and intellectual ability. Each subscale is scored from 1 (within the norma l range for subject 's age) to 4 (most severe autistic symptomatology). Total scores less than 30 are considered not indicative of autism; 30 to 36 are considered indicati ve of mild autism; and over 36 are considered indica tive of severe autism. Ratings on the CARS were made at the time of diagnosis. Scores were obtained by rating a 20 to 30 minute play interaction with a familiar adult, using standard scoring instructions (Schopler et al., 1980). In some cases , the rater interacted directly with the child and scored the CARS after the play interaction . In other cases, the rater scored the CARS from a videotap e of a play interaction with a differen t adult. Raters were highly experienced with young autistic children and had been trained extensive ly on scoring . Interrater agreement was calculated on approximately 50% of the subjects. The Pearson correlation coefficient among raters was 0.9 4 for the overall CARS score. Raters were not aware of the hypotheses of the study . Mean CARS scores for the two groups appear in Table 1. Attachment security rating. Attachment behavior was rated from videotapes of mother-child pairs in a modified Strange Situation paradigm. After 10 minutes of mother-child free play, a stranger (usually female) entered the room , conversed with the mother for 1 minute, and invited the child to play. The mother left the room, telling the child she would return shortly. The stranger and child were toge ther for 3 minutes , after which the mother reentered the room . As the mother greeted the child, the stranger left the room , and the mother and child were together for 3 more minutes . Similar modifications of Ainswort h's paradigm have yielded results consistent with those obtained when the complete procedure has been used (Lewis and Feining , 1989). Slight variations in procedure occasionally occurred. Some children were left alone for a few seconds before the stranger entered . The time with the strange r was cut short for a few subjects when the child became severely distressed. Motherchild postreunion time was occasionally shortened if one or the other mistakenly left the room prematurely. In such cases, ratings were made using available data. Because of the developmental status and unique behavioral repertoire of the autistic group , traditiona l Ainsworth A-B-C classifications were not used . The subjects in the present study were considerably older than the traditional age for which the Ainsworth et al. (1978) system was developed, but most did not have sufficient verbal or interpersonal skills to use the attachmen t scoring system devised for 3- and 4-year-olds (Cassidy and Marvin , 1989, unpublished manuscript). Further more, existing attachment classification systems did not account for the often idiosyncratic behavioral displays of the autistic subjects . For these reason s, a continuous rating system , as sugJ . Am .A cad . Child Adolesc. Psyc hiatry, 30 :3, May 1991

TABLE

SEC

2. Correlations among the Overall Security Score and the Four Interactive Subscale Scores

PS

CM

0.65**

Autistic Group (N 0.31 0.82***

PS CM CR SEC PS CM CR

*p

0.63**

~ 0 . 05,

** p

CR

17) - 0.70** -0 .52* -0 .28

Nonautistic Group (N = 17) 0.35 -0.51 * -0 .29 0.75*** -0.11 ~ 0 . 0 1,

*** P

PA

=

-0.75*** -0 .60** -0 .39 0.53** -0 .89*** - 0. 82*** -0.51* 0.43

~ O .OO I.

gested by Lamb and colleagues (Lamb et aI. , 1984), was developed based on a 5-point scale . This was comp leted after the four traditional Ainsworth interac tive subscales (Ainsworth et aI., 1978) were rated: (1) proxim ity and contact seeking (PS); (2) contact maintenance (CM); (3) contact resistance (CR); and (4) proximity avoidance (PA) . After completing ratings on the four subscales , raters assigned a score of 1 to 5 as an overa ll security score (SEC) to reflect their general clinical judgment of attachment security (1 = clear signs of insecurity with no signs of security; 2 = clear signs of insecurity mixed with some low-level or weak indications of security; 3 = signs of both security and insecurity are present, and they are approxi mately equal in strength; 4 = clear signs of security mixed with some lowlevel signs of securit y; 5 = clear signs of security with no indication s of insecurity ). Detailed instructions and behavioral descript ions of this scori ng system can be obtained from the first author. Raters were thoroughly trained before tape scoring. The videotapes of the autistic groups were rated by a pair of raters (out of a pool of four rater s) who had achieved acceptable reliability (see below); raters scored eac h tape independent ly and later resolved any scoring differences. Two of the four raters reestablished reliability and indepen dently scored all the tapes of the nonautistic group (with reliabilities checked on 50% of the nonautistic tapes). Interrater agreements were calcula ted as intraclass correlations with in and across scoring pairs; this was done to avoid falsely high Pearson corre lations that might be obtained by systematic , consistent differences between scoring partners . Agreement within pairs was based on the independent ratings made before scoring differences were resolved . For the autistic group , the intraclass correlation for PS was 0 .77, for Clvl was 0.73 , for CR was 0 .75 , for PA was 0 .86 , and for the overall security score (SEC) was 0 .75. For the nonautistic group, the intraclass correlation for PS was 0.81, for CM was 0.73 , for CR was 0.72 , for PA was 0.86, and for SEC was 0.77. The validity of the SEC was examined by correlating it with the four interactive subsc ale scores for each group separately (Table 2). In both gro ups, as expected, SEC was positively corre lated with PS and Clvl (which were highly intercorrelated) and significantly negatively correlated with 485

ROGERS ET AL. T ABLE 3. Descriptions and Comparisons of the Two Subject Groups on the Five Attachment Ratings: Overall Security Score (SEC). Proximity Seeking (PS). Contact Maintenance (CM). Contact Resistance (CR), and Proximity Avoidance (PA)

Autistic Group

X

SEC PS

CM CR

PA

3.2 2.7 2.3 2.7 3.3

Nonautistic Group

SD

X

SD

t(32)

1.4

3.1 2.8 2.2 2.8 3.0

1.4 1.9 1.8 2.0 1.5

0.12 -0 .14 0.30 -0.23 0.60

1.7

1.6 1.8 1.6

gross motor levels on the profiles. In addition, there were trends toward significant correlations with chronological and mental age and fine motor skills. Thus, the SEC score showed numerous relationships with measures of developmental status within the autistic group. In contrast, within the nonautistic group, correlations among the SEC score and developmental variables were nonsignificant. Thus, attachment security scores appeared to be independent of these developmental characteristics in the nonautistic group . Discussion It was hypothesized that , given the severity of their social

CR and PA (which were also highly interrelated); all the correlations were in the expected direction, and most reached statistical significance. Thus , the SEC score was felt to be an adequate summary measure of the behaviors commonly thought to reflect security and insecurity of attachment. Results

Group Differences T-tests were performed to compare the groups on CA , MA, IQ , SES, and the six profile subscales. As can be seen in Table 1, there were no significant group differences on CA, MA, IQ, SES, or profile subscales involving self-help or gross motor skills. However, there were significant differences between the two groups on four profile subscales : cognition, fine motor, language, and social skills . For each of the skills, the autistic subjects had significantly lower developmental levels than the comparison subjects . Thus, the autistic subjects appeared to be more severely handicapped in multiple areas than the comparison subjects, even though they were matched on IQ test scores. Group differences in attachment behavior were also examined with t-test comparisons. As can be seen in Table 3, the autistic and nonautistic groups did not differ on any of the interactive subscales or the SEC. Thus, contrary to prediction , the autistic group did not demonstrate greater insecurity than the nonautistic group . A chi-square analysis was performed to examine whether the distribution of subjects among the five SEC categories differed by group . This analysis revealed no differences in distribution, X2 (df = 4, N = 34) = 1.53, p = 0.82 . The mean SEC scores of both groups were approximately 3.0 (Table 3). On the average, both groups demonstrated signs of both security and insecurity that were approximately equal in strength. Thus, contrary to the original hypothesis, neither group appeared predominantly insecure.

Relationships among Attachment and Independent Variables To examine the relationship between severity of developmental handicap and attachment security, the overall SEC score was correlated with the developmental variables and the CARS scores for each of the groups. The correlational patterns differed between the two groups. As can be seen in Table 4, within the autistic sample, the SEC score was significantly positively related to cognitive , language, and

486

deficits, the autistic subjects would demonstrate greater levels of insecurity than the nonautistic subjects. However, this hypothesis was not supported . The autistic sample was not found to differ from the comparison group on a continuous rating scale used to measure attachment behavior, even though the autistic subjects demonstrated greater developmental impairments in several areas than the comparison subjects . Since this group of autistic children had relatively high IQs, it is important to address the question of generalizability of these findings to lower IQ autistic children. While this study cannot provide data on this issue, the fact that the current finding of lack of differences in attachment security between the autistic and the comparison subjects replicates the findings of Sigman and colleagues (Sigman and Ungerer , 1984; Sigman and Mundy , 1989) and Shapiro et al. (1987), which involved same age but lower IQ subjects than these, appears to indicate that the findings may apply to young autistic children in general. No relationship was found between severity of autism, as measured by the CARS, and attachment security. This finding replicates Shapiro et al. (1987) . It contradicts the view that the source of the relatedness deficit in autism stems from an absolute incapacity to form positive social relationships with others. Thus, it is perhaps time to put to rest the notion that autism is primarily an attachment disorder and that autistic children are generally unattached to their caregivers . It was further expected that, given the psychiatric impairments of both groups of children, quality of attachment in both groups would be predominantly insecure. This hypothesis was also not supported. Neither group demonstrated predominantly insecure attachment behaviors; rather, both demonstrated a balanced picture. Since the scoring system used here has not been normed on nonhandicapped children, it is not known how different these results are from what would be expected in a normal population. However, expected levels of insecurity were not found in either group. The third hypothesis that attachment security and general developmental level would be related in the autistic subjects was supported. Many positive relationships between attachment security and developmental levels were found for the autistic group. However , no such relationships existed for the nonautistic subjects. Why might this be? Construction of an internal working model of the mother may be a more cognitively demanding task for autistic children than for normally developing or J. Am. Acad. Child Ado/esc .Psychiatry , 30:3. May 1991

ATIACHMENT COMPARISON

TABLE 4 . Correlations between Overall Security Score and Independent Variables for Autistic and Nonautistic Groups CA SEC

SEC

MA

0.41

0.42

t

t

0.12

0.26

IQ 0 .14

COG

-0 .26

Autistic Group (N 0 .57

* 0 .39

LAN

CARS

0.15

=

17) 0.59

** = 17)

Nonautistic Group (N 0.01 0 .29

GMOT

FMOT

SH

SOC

0.53

0.42

0 .39

0.38

*

t

0 .04

0.42

0 .39

0.01

t p ::SO . 10, *p ::sO.05, **p ::SO .OI, ***p ::SO.OOI .

nonautistic developmentally handicapped children. Because of specific deficits in emotion perception (Hobson, 1989) and expression, the young autistic child may not have an adequate affective data base concerning the mother. Nor, because of deficits in intersubjectivity, does the young autistic child develop normal awareness of the mother's subjective or internal experiences (e.g. , intentions, motivations, focus of attention) (Baron-Cohen, 1989). This store of affective and intersubjective information , which the authors suggest may form a large part of the data from which most young children construct a working model of the mother, appears unavailable to the young autistic child . This leaves him or her essentially a behaviorist, as Baron-Cohen (1989) has suggested , who must develop an internal working model of the mother based on behavioral contingencies that the child has experienced and remembered . Since the autistic child lacks so much affective and intersubjective information about the mother, developing a working model of her becomes a difficult cognitive task. Thus , it is suggested that (assuming an adequate experience of caretaker sensitivity/ responsivity) the young autistic child's level of develop mental or cognitive ability will greatly influence the rate at which he or she develops an internal, secure working model of the mother . For the nonautistic, developmentally delayed children in this study, it is suggested that they have no particular difficulties processing affective and intersubjective experiences with their caretakers, or at least no more difficulty processing this type of information than any other type of information. Their psychiatric problems can be seen as due, in part , to difficulties in the interpersonal sphere , and their attachment ratings reflect primary aspects of their relationships rather than their developmental status, since other studies of children with developmental delays have reported normal attachment security distributions (Blacher and Meyers, 1983; Stahlecker and Cohen, 1985; Easterbrooks, 1989). The present finding of relationships between attachment security and developmental status in the autistic subject s, but not the nonautistic developmentally delayed subjects, suggests that autistic children can construct attachment relationships marked by security but, because of their unique handicap, may do so through different processes than their nonautistic peers. A clinical implication of these findings is that it is important to attend to the quality of attachment in young autistic children. Evidence of security may attest to both adequate caretaker sensitivity and responsivity and the presence of sufficient cognitive ability in the child to have formed a l .Am .Acad. Child Adolesc . Psychiatry , 30:3 , Ma y 1991

secure working model of the caretaker. Evidence of insecurity should raise questions in the clinician concerning both cognitive functioning in the child and caretaking sensitivity/ responsivity to child cues that can be extremely complex, subtle, and idiosyncratic . Concerns in either of these areas can then be addressed through specific intervention efforts of the early intervention team and the child clinician working with the young autistic child and his or her family . In developing the classification approach used in this study, the authors sought to develop a scoring system that would reflect the core concept in attachment theory of "felt security" (Sroufe and Waters, 1977), while being sensitive to signs of felt security in very young autistic children , a group who typically demonstrates profound deficits in social behavior and development. The scoring system that was developed retained dimensions of attachment behavior con sidered crucial to the behavioral expression of attachment patterns (i.e. , proximity, contact, resistance, and avoidance), without imposing specific patterns of behavior typical of normally developing infants onto autistic children. As found earlier by Sigman and Mundy (1989), adapting scoring systems to increase their sensitivity to attachment behaviors of young autistic children makes it difficult to compare findings to others that have used the A-B-C system. As others have reported (Gaensbauer et al., 1985), using a continuous attachment rating system changes the proportions of children considered secure and insecure, particularly in terms of reducing the proportion of securely attached children . Thus, the rating system used in the present study does not permit comparison with other groups of either typical or atypical children . In summary , the present study found that there were no differences in the overall security of attachment in young autistic children and young children with similar levels of intellectual performance but with other psychiatric diagnoses. However, attachment security appeared to be mediated by several developmental variables in the autistic group , but not in the comparison group, suggesting that attachment formation may involve different processes in the two groups . To try to more fully understand the development of attachment relationships in autism, further research is essential. Validation of the use of the Strange Situation with autistic children, both with the present modified scoring system as well as with other classification approaches needs to be carried out. The role of individu al differences in caretaker behavior in the development of attachment security in autistic children needs to be examined. Finally , further exploration of the relationships between developmental level

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and attachment security suggested by this study could be assessed through longitudinal investigation s of young autistic children . References Ainsworth, M . D. S. , Blehar , M . C ., Waters , E. and Wall , S . (1978), Pal/ems of Attachment . Hillsdal e, N.J .: Lawrence Erlbaum . Baron-Cohen , S. (1989), Are autistic children behaviorists? J. Autism Dev. Disord ., 19:579- 600 . Bayley , N. (1969), Bayley Scales of Infant Development. New York: Psychological Corp . Blacher, J. & Meyers, C. E. (1983), A review of attachment formation and disorder of handicapped children. Am . J . Ment . Defic., 87:35937 1. Bowlby , J. (1958) , The nature of the child's tie to his mother. Int . J . Psychoanal. , 39:350-373. - - (1969), Attachment and Loss. Volume I . New York: Basic Books. Dahl, E. K. , Cohen, D. J. & Provence , S. (1986), Clinical and multivariate approaches to the nosology of pervasive developmental disorder s. J . Am . Acad . Child Adolesc. Psychiatry, 14:383-394. Easterbrooks , M . A. ( 1989), Quality of attachment to mother and father. Child Dev. , 60:825-830. Fein, D., Waterhou se , L., Lucci, D. & Snyder, D. (1985), Cogn itive subtypes in devel opmentally disabled children . J . Autism Dev , Disord., 15:77- 95. Gaensbauer , T . J. , Harmon , R. J., Culp A. M . , Schult z, L. A. , van Doorninc k, W. 1. & Dawson , P. (1985) , Relationships between attachment behavior in the laboratory and in the caretaking en vironment. Infant Behavior and Development, 8:355-369 . Hobson, R. P. (1989) , On sharing experiences. Development and Psychopathology, 1:197-205. Lamb , M. E. , Thomp son , R. A. , Gardner , W. P. , Charnov , E. L. & Estes , E. (1984) , Security of infantile attachment in the Strange Situation . Behavioral and Brain Sciences, 7: 127- 147 . Leiter , R. G. (1979) , Leiter International Perf ormance Scale. Chicag o: Stoelting. Lewis , M. & Feining, C. (1989) Infant , mother and mother-infant interaction behavior and subsequent attachment. Child Dev., 60:831837 .

488

Mahler, M . (1952), On child psychosis and schizophrenia. Psychoana!. Study Child. 7 :286-305 . Rescorla, L. A. (1986), Preschool psychiatric disorders. J . Am . Acad . Child Adolesc . Psychiatry , 25:162- 169. Rogers, S. J. & Lew is, H. (1989), An effect ive day treatment model for young children with pervasive developmental disorders. J . Am. Acad. Child Adolesc . Psychiatry, 28:207- 2 14 . - - DiLalla, D. (1990), Age of symptom onset in young children with pervasive developmental disord ers . J . Am . Acad . Child Adolese . Psychiatry, 29:863-872. - - Herbi son , J. , Lewis, H. , Pantone, J . & Reis, K. ( 1986), An approach for enhancing the symbolic , communicative and interpersonal functioning of young child ren with autism and severe emo tional handicaps. Journal ofthe Division of Early Childhood, 10:1 35148. Schafer , D. S. & Moersch , M . S. (1981), Dev elopmental Programming fo r Infants and Young Children. Ann Arbor, MI: University of Michigan Press. Schopler , E., Reichler , R . , DeVelli s, R. & Daly , K . (1980) , Tow ard objective classification of childh ood autism. J . Autism Dev. Disord ., 10:91- 103. Shapiro , T. , Sherman, M . , Calamari, G . & Koch , D. (1987), Attachment in autism and other developmental disorders. J . Am . Acad . Child Adolesc , Psychiatry , 26:480-484 . Sigman , M. (1989), The application of developmental knowle dge to a clinical problem . In: The Emergence of a Discipline, ed . D. Cicchetti. Hillsdale , NJ : Lawrence Erlbaum . - - Ungerer, J . (1984), Attachment behaviors in autistic children . J. Aut ism Dev. Disord ., 14:231-243. - - Mund y, P. (1989), Social attachments in autistic children. J . Am . Acad . Child Adolesc. Psychiatry, 28 :74-81. Sroufe , L. A. & Waters, E. (1977) , Attachment as an organizational construct. Child Dev.. 48:1184-1199. Stahlecker, 1. E. & Cohen , M. C. ( 1985), Applicat ion of the strange situation attachment paradigm to a neurologicall y impaired population . Child Dev ., 56:502-507 . Stutsman , R. (1948), Merrill-Palmer Scale ofMental Tests. New York : Harcourt-Brace-Jovanovich . Wasserman , G. A. (1986), Affective expressio n in norm al and physically handicapped infants. J . Am . Acad . Child Adolesc . Psychiatry , 25:393- 399 .

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