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The Coventry Grid Interview (CGI): exploring autism & attachment

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The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

The Coventry Grid Interview Address for

correspondence
(CGI): exploring autism and E-mail: Charlotte.

attachment difficulties
Flackhill@sussex
partnership.nhs.uk

Acknowledgements
Charlotte Flackhill, Sarah James, Richard Soppitt
The authors would
and Karen Milton, Sussex, UK
like to thank Heather
Moran for her support
Editorial comment and encouragement
throughout the
This paper builds on the earlier work of Heather Moran who developed what came to development of CGI
be called the Coventry Grid to try to differentiate the criteria for autism and attachment and for the inspiration to
disorder (Moran, 2010). The authors work within a Child and Adolescent Mental Health consider developing this
Service, CF being a Principal Clinical Psychologist, SJ and RS being Consultant clinical tool further.
Psychiatrists and KM a Senior Occupational Therapist. In this paper, they have used
the Coventry Grid and converted it into an interview format to allow clinicians to use
Note: The term ASD is
this with parents and others during the assessment process. It is in its early stages and
used in this paper as the
the authors would welcome comments from readers on the content and its usefulness focus is on diagnostic
in practice. criteria and ASD is the
current diagnostic term
(DSM5 APA, 2013). In other
Some children have autism, some have attachment difficulties and some have both. By
papers within the GAP
definition, the social and communication difficulties experienced by those with autism Journal, the preference
can create attachment problems. It is therefore difficult to ascertain whether an autistic is to use autism, autism
child has an attachment disorder in addition to his or her autism or whether some of spectrum or Asperger
the difficulties encountered are a function of their autism. The Coventry Grid Interview syndrome, as not all
autistic children, adults
(CGI) aims to help clinicians clarify this. They are keen to point out though that this has
and their families
not been checked for reliability or validity and it should not be used in isolation, but form consider themselves
part of the whole diagnostic process. to be disordered.

Introduction
In order to support better differentiation between group of children than those with an attachment disor-
autism and attachment difficulties, the Coventry Grid der. Rather, it refers to all kinds of attachment difficulties
was initially designed by a group of clinicians in severe enough to affect the ability to develop mutually
Coventry CAMHS. This was discussed with the West supportive relationships with family and friends.
Midlands Regional ASD group before being written up
by Heather Moran in 2010 (Moran 2010) and revised in It is hoped that this paper will carry on a key aim of
2015 by Moran with a London/South of England group the first paper, namely to stimulate discussion among
of speech therapists who work in youth justice. It was clinicians and researchers about the need for tools
designed for those of broadly average/mild learning which provide differential diagnosis between autism
disability but not for children with severe learning and attachment problems. It is also hoped that inter-
disability. Attachment problems/difficulties are used in ested clinicians will continue the tradition of providing
this paper, and by Moran in 2010, to refer to a broader feedback on the CGI, clarifying whether the ideas

62 GAP,18,1, 2017
 The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

identified so far are relevant to them and whether they heuristics can be counter productive with an either/or
think there is a need to develop such work further. This rather than a both/and approach. Such reductionism can
paper seeks to refine and develop the tool based on lead to clinicians negating either the ASD or the attach-
our own extensive clinical experience working in the ment issues when there is co-morbidity. Families can be
arena of ASD since the mid 1990s. disadvantaged in a number of ways for having a purist
lens applied and an ASD diagnosis not given because
Attachment patterns describe the degree to which of concurrent attachment disruption history. Having a
the child is able to use the caregiver as a secure more robust way of understanding the attachment con-
base (Ainsworth et al, 1978; Bowlby, 1982). Whereas tributions to a clinical picture will hopefully provide more
securely attached children seek proximity with the confidence in establishing co-morbidity and also inform-
caregiver resulting in the reduction in distress, inse- ing a clinical decision. Such decisions should always
curely attached children deal with the distress with little trump reliance on diagnostic instruments, which should
reference to the parent or do not attain efficient relief only inform, as opposed to over-ride, clinical judgement.
of distress. For example, children may hurt themselves
but go off to find a solitary space in which to calm down Findings from the Romanian
as opposed to seeking out physical comfort from a orphan studies
primary caregiver, actively avoiding being comforted The Romanian orphan studies indicate the overlap
by others (Ainsworth et al, 1978). However, children with with attachment disorder and autism. These children
ASD often present with aloof, disinhibited or detached showed attachment difficulties and some appeared
attachment behaviours and insecure attachment styles to have autism, termed ‘quasi-autism’ as it was not
are often seen in female autistic presentations clinically, typical (Rutter et al 2001). Such autistic characteristics
with marked separation anxiety. were not found in a similarly studied sample of typical
children in the UK adopted in the first six months of life.
One of the insecure types is the insecure disorgan- The Romanian adoptees were somewhat different from
ised-disorientated pattern (Main and Solomon, 1986). many children with typical autism in the improvements
Here the child displays fearful or contradictory behav- they showed between the ages of 4 and 6 years and
iours such as freezing during proximity seeking or the extent of their social approach (Rutter et al 1999).
bizarre responses to being distressed. These are often
played out in story-stem assessments which are a way Studies have shown that school age adopted children
of assessing child attachment presentations through referred with indiscriminate friendliness have very
play (Green et al, 2000). This pattern is also associated complex and sometimes disabling neuropsychiatric
with particularly impoverished psychosocial histories problems. Kocovska and colleagues (2012) recruited 34
(Minnis, et al 2009). Although none of the insecure adopted children, referred with symptoms of indiscrimi-
categories is considered to be a clinical disorder, they nate friendliness and a history of severe maltreatment in
are seen as a pattern of relationship functioning that their early childhood. The overwhelming majority of the
confers later psychosocial risk. adopted/indiscriminately friendly group had a range
of psychiatric diagnoses, including Attention Deficit
The need for an instrument to Hyperactivity Disorder (ADHD), Post-Traumatic Stress
clarify the presence of ASD and/or Disorder (PTSD) and Reactive Attachment Disorder
attachment difficulties (RAD) and one third exhibited a disorganised pattern
It is assumed that autistic conditions and attachment of attachment. Of the group, 70 per cent appeared to
difficulties are two real and different phenomena. have possible or likely ASD but this may have been
However, it is acknowledged that they are in part social apparent rather than real. Perhaps an instrument such
constructions and distinguishing between the two and as the CGI could help clarify the differences between
the interpretations made are down to the individual clini- attachment and autism and help clinicians to decide
cians (bias). The dualistic assumptions within diagnostic whether a child has one or both disorders or neither.

GAP,18,1, 2017 63
The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

Sensory processing, autism and delivered in the parental home by a trained health or
attachment difficulties social care worker with experience of working with
The authors of this paper wanted to extend and children and young people, highlighting parental
develop the original Coventry Grid to include sensory sensitivity, responsiveness and communication (NICE
processing questions. It is recognised that sensory guideline [NG26] Children’s Attachment, November
issues are present in both typically autistic and attach- 2015). Trauma related issues are common with attach-
ment or post institutional deprivation populations and ment disorders and require trauma based interventions.
in children with many other conditions. For example, Autism specific educational interventions aim to explic-
Beckett et al (2002) found patterns of rocking, self itly develop communication and language and social
injury, unusual sensory interests, and eating problems understanding – eg Early Bird parent training for parents
in children who were adopted from institutional care. (National Autistic Society), Social Stories (Gray, 2015),
Of the institutionalised children 47 per cent rocked Circle of Friends (Newton and Wilson, 2010), and social
at the time of UK entry and 24 per cent engaged in skills groups – and to enhance their theory of mind.
self injurious behaviour. By the age of 6 years, the
percentages had decreased to 18 per cent and 13 per Early intervention for attachment disorders is likely to
cent, respectively. At the time of arrival, 11 per cent of reduce the risk of the later development of personality
the children displayed unusual sensory interests and disorders. Combinations of autistic and attachment
at 6 years, 13 per cent of the children did so. At the difficulties are very challenging and will require a joint
age of 6 years 15 per cent of the children experienced approach addressing both, eg psychotherapy (Reid,
difficulties with chewing and swallowing solid food. The Alvarez and Lee, 2001). Reduced or inconsistent
primary factor affecting the prevalence and persistence interactions with early caregivers are associated with
of the behaviours appeared to be the length of time the deficits in executive function and a decreased ability
children had spent in institutional care. to self-regulate; and can lead to lifelong issues in
physical and mental health, including an inability to
Purpose of the Coventry Grid Interview form and maintain appropriate emotional attachments.
The CGI does not seek to be a standalone diagnostic These challenges are often compounded by problems
assessment tool of either autistic or attachment difficul- with self-regulation, self-concept, and anxiety (Ashton,
ties but rather to supplement the understanding of very O’Brien-Langer and Silverstone 2016).
complex children where there may be neurodevelop-
mental and environmental factors at play. As Keenan Issues in the diagnosis of ASD
et al (2016) conclude, clinicians need help to tease out and attachment difficulties
the complex interplay of children’s biologically based In the ASD diagnostic process, clinicians are often
social and emotional interactive deficits, children’s confronted with dilemmas on how much weight to place
subjective experience of attachment relationships, on disruptions to attachment, such as parental mental
and caregivers’ experience and responses within this illness and separation from caregivers. Some clinicians
challenging clinical picture. There is an ever increas- feel paralysed about proceeding to make a diagnosis of
ing demand for bespoke interventions to reduce later ASD in the presence of complex psychosocial caregiv-
psychiatric morbidity and hence a more efficient use of ing histories and sometimes a hypothesis of attachment
public finances. difficulties vs ASD is seen as mutually exclusive. The
reality is more complex and often both presentations
Implications for intervention are seen with the familial neurodevelopmental disorder
There are treatment and psychoeducation implications leading to difficult professional/parent attachments
from the differentiation between attachment difficulties which can complicate the neutrality of the assessing
and those on the autism spectrum. Attachment based team. For example, it is not unusual that a parent with
interventions include parent-child attachment attune- ASD, perhaps not yet diagnosed, presents with high
ment work (eg using video feedback programmes levels of anxiety. Their personal style might cause

64 GAP,18,1, 2017
 The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

anxiety and concern among the professional team and autistic presentations. Elizabeth Newson first recog-
they might be viewed as unhelpful to the process and/or nised or named Pathological Demand Avoidance or
to have led to the problems displayed by their child. If PDA (Newson, Le Marechal, D, 2003) later renamed by
these parents do have ASD themselves or mental health others as Extreme Demand Avoidance (EDA) (O’Nions,
issues, this may have led to attachment difficulties in Christie, Gould, 2014). There is still debate among
their child, but it is also true that the child might have clinicians as to whether PDA should exist as a separate
ASD. Separating out these two possibilities can be dif- diagnostic category. As yet it is not included as such
ficult and confirmation of the diagnosis is unlikely to be in DSM-5 or ICD-10. Those clinicians who feel it does
achieved quickly, observations and assessments being warrant a separate diagnostic category feel it fits within
needed over time. The CGI might help with this process. the autism spectrum whereas others question whether
it is better placed as an attachment disorder.
Collectively, the authors are trained in ASD diagnostic
tools (3Di, (Skuse et al, 2004), DISCO (Wing, et al Children with autism and features of PDA have surface
2002), ADI-R (Lord et al 1994) and ADOS 2 (Lord et al, similarities with those with attachment difficulties. There
2012) and work in an NHS CAMHS Tier 3 service and is a lack of research to date linking attachment difficul-
the Child Development Team in Sussex. Accordingly, ties/disorder with PDA; however, we notice that these
they have sought to adapt the Coventry Grid to make it children often appear to find it hard to make trusting
user friendly during assessment, where time is limited. (securely attached) relationships. Further work is needed
It is often the case that the attachment issues are to disentangle this important area. Indeed, O’Nions et al
considered in less detail after the standard ASD tools (2016) reinforce this in their conclusion suggesting:
have been used. Furthermore, post diagnosis, a clear
“It may also be of interest to examine attachment
understanding of attachment issues is important to tailor
patterns and the processes by which these may
individualised support programmes and target scarce
come about in children with PDA.”
social care, voluntary sector or parenting resources. For
young people with ASD, the visual presentation of mate-
rials, interventions to enhance social understanding The controversy around PDA/EDA relates in part to
and consistent and calm routines are paramount. Often whether or not it falls on the autistic spectrum. Wing
there is an emphasis on delivery through school. Family and Gould have incorporated it into the DISCO-11 as
work can be delivered via parent groups. Interventions a subcategory of autism. Further work by O’Nions et
for attachment include theraplay (Jernberg and Booth, al (2016) found PDA within the ASD population to be
2001), art therapy or Eye Movement Desensitization and consistent with Newson’s descriptions characterised
Reprocessing EMDR (Shapiro 1994) if there has been by lack of co-operation, use of apparently manipulative
trauma within the family. Parenting work may include behaviour, socially shocking behaviour, difficulties with
identifying parental mental health issues and supporting other people, anxiety and sudden behavioural changes
parents. In practice a child may need a combination of from loving to aggressive. Further ongoing work by
these approaches. Kaushik (RCPsych CAP Faculty Annual Conference
2015 proceedings) has recognised that there are
Pathological Demand Avoidance, also associations between PDA, ADHD, and conduct
attachment difficulties and ASD disorder, the latter two diagnoses of which can be
There are divergent opinions among colleagues, linked to the environment, poor early caregiving and
some of whom have been told that it is impossible attachments (Kumsta et al, 2015).
to disentangle attachment difficulties from autistic
conditions or to identify attachment issues within the With further work, it maybe that the CGI can help to
ASD diagnostic presentation. There are of course other clarify the defining criteria for ASD, PDA and attach-
diagnoses and debates, which overlap with the whole ment, but as yet this is not possible. With the increasing
diagnostic conundrum, which often surrounds complex interest in PDA over recent years, it is possible that

GAP,18,1, 2017 65
The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

further refinements in future may find attachment issues Colleagues showed a real interest in the first draft of the
inform PDA presentations within the ASD diagnostic CGI and it was circulated to many clinicians in Sussex
pathway and also help to inform more appropriate and feedback was requested, which proved largely
educational and therapeutic interventions. positive. In some cases, in addition to the previously
gathered history and data from assessment tools (eg
Development of the Coventry Grid ADI and ADOS), it helped clarify that the young person
Interview was presenting with attachment difficulties as well as
The clinicians in Coventry worked together, identifying autism. Feedback also included some suggestions for
the symptoms of autism and then thought about how further development for the interview schedule, such as
these were different and similar to those symptoms the addition of specific sensory processing questions.
presented in children with attachment problems and An Occupational Therapist fully trained in sensory
put these into a Grid format (Moran 2010; 2015). The attachment intervention, based on the work of Eadaoin
lead author of this paper (CF) had referred to the Grid to Bhreathnach, a Consultant Occupational Therapist
help her thinking in complex cases but wanted to adapt and attachment counsellor (Bhreathnach, 2008), was
it so that experienced clinicians would have a more engaged to assist in the development of the sensory
accessible tool to use with parents in an assessment questions.
situation. The authors were also mindful that only a few
sensory discriminatory behaviours were included within The authors found some of the original items were
the original Coventry Grid and the DSM 5 (APA, 2013) not as discriminatory as others and also some were
now gives greater weight to sensory issues in ASD. difficult to turn into an interview format and so these
were excluded; for example the item about eating
The primary author set about doing this by turning most disorders could apply to both ASD and attachment. In
of the elements in the grid into questions phrased in such the authors’ experience, there have been female ASD
a way as to elicit a ‘yes’ or ‘no’ response. The interviewer presentations with some superficial similarities with the
can ask supplementary questions to give richer detail attachment difficulties sub-group (eg using pretence
when appropriate. However, by ticking the most appro- and fantasy worlds). Interestingly, research has shown
priate box (YES or NO) after each item, it enables the while children with ASD do show a range of normative
interviewer to tally up the scores at the end and see how attachment behaviours, they were less likely to use
many responses pointed towards attachment and how the caregiver as a secure base and as a co-regulating
many pointed towards ASD (see Appendix 1 for the ques- agent than their neurotypical peers (Keenan et al 2016).
tions and scoring). In the early stages of this process, the
authors were aware of how unhelpful it can be for families Validity of the CGI
and children to have an either/or diagnosis. In complex The Coventry Grid appears to have a reasonably
cases very often there is co-morbidity but it remains wide clinical acceptance and empirically appears
helpful to try and understand the possible relative con- to have face validity, being developed and used by
tributions of the neurodevelopmental and environmental Moran (2010, 2015). With regard to construct validity,
factors. It is particularly important for informing clinical convergent and divergent validity have preliminarily
intervention. For example, a child who is identified as been considered through comparison with ADI and
having mild ASD but significant attachment difficulties ADOS scores, but this is only in a very limited number
is likely to benefit from systemic and/or psychodynamic of cases and further research is needed to establish
therapy (depending on the family circumstances) and construct, convergent and divergent validity. Further
attachment interventions at school more than a child with research could also aim to establish predictive validity
severe ASD and more mild attachment difficulties. The by reviewing and following up on young people 5
child with more severe ASD may benefit from modified years after discharge to see whether the diagnosis
Cognitive Behaviour Therapy (CBT) when there are given still ‘fits’.
accompanying mental health difficulties.

66 GAP,18,1, 2017
 The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

Reliability in NICE guidelines for ASD in pre-schoolers), they

Initial use of the measure in joint clinics yielding the usually make good progress compared to controls. A
same outcome, appears to suggest this is a reliable child with ‘quasi autism’ should be in the group which
measure. Again further research is needed to establish improves.
reliability properly.
Rutter et al (1999) have established that there are
Limitations improvements in social approach within stable
The scoring of the interview does not provide cut off adoptive homes and that there may be more change
scores or definitive answers. The CGI merely aids towards neurotypical and secure attachment behav-
the interviewer’s thinking in her/his assessment and iours than would be seen in ASD alone. One could
differential diagnosis in what are often complex speculate that the attachment issues should improve
presentations. This is a work in progress and further within a stable home more quickly than typical ASD
feedback to refine the questions would be welcome. presentations and that recalcitrant presentations may
The CGI does not address severe intellectual disability represent more severe comorbidity, which remains
or any other co-morbidities and hence needs to be an chronic, even with stable family life. The complexity of
adjunct to wider multi-professional diagnostic pathway associated psychosocial instability and inconsistent
and screening processes. or hostile or neglectful parenting may increase the
likelihood of developing conduct disorder in later
Concluding comments childhood and adolescence. Accordingly, the CGI
The relationship between attachment patterns and may also flag up concerns about antisocial person-
autism is a complex one. The medical model encour- ality development.
ages a search for categorical diagnostic labels for
children. The Coventry Grid attempts to differentiate The team thinks it important that clinicians with ASD
between broadly defined ASD and attachment diagnostic expertise but also clinical experience with
behaviours. It is likely, however that some of the more attachment difficulties use the CGI at the end stages
complex children seen in CAMHS ASD clinics may of an ASD assessment. A potential drawback of such
have behaviours which are related both to a primary an instrument is that it could lead to an unbalanced
neurodevelopmental deficit and to a disordered or focus on attachment issues to the exclusion of an
disrupted relationship with the primary caregiver. ASD diagnosis, in inexperienced hands. If there are
additional attachment issues, a more systemic family
Crittenden et al (1999; 2000) emphasise the dynamic therapy approach may be appropriate. The team
process of adaptation of humans to their environment. would welcome further feedback from clinicians on
Change in patterns of attachment should be expected the clinical usefulness of the tool or suggestions for
as a function of both change in circumstance and discriminatory items. It is hoped that the CGI will
also individual maturation. Neurotypical children use provide a much needed lens through which teams
subtle social responses to regulate parental emotion can disentangle attachment issues from mixed ASD
(eg the use of coyness to down regulate aggression). presentations and allow clinicians to think of both,
Children who have social communication disorders as well as being more confident to discount ASD as
and who are not neurotypical are less likely to be able an adjunct with the standardised instruments such
to do this, so maladaptive patterns of attachment may as Autism Diagnostic Interview, Revised (ADI-R),
be propagated. Equally, Rutter et al’s (1999) seminal Developmental, Dimensional and Diagnostic inter-
work on adopted Romanian children with quasi-autism view (3Di) and Diagnostic Interview for Social and
following institutionalised care and emotional dep- Communication Disorders (DISCO). It is hoped that
rivation shows that if a child has the right kind and this empirically useful clinical tool can be further vali-
enough input (more than 30 hours, as recommended dated and improved in future studies.

GAP,18,1, 2017 67
The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

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GAP,18,1, 2017 69
The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

Appendix 1: Coventry Grid Interview

(Flackhill, James, Soppitt and Milton, 2017)

Purpose of the interview

The CGI is intended to help clinicians to determine the extent to which a child has
autism (ASD) or attachment difficulties or both or neither. For each item, one response
suggests ASD - and another response suggests attachment issues. Clearly, these are
based on what is typically found in each group but there will be exceptions to these.
As such, this interview should be used as a guide only and as a prompt for further
questions. Clinical judgement, early history, exposure to trauma and other data from
diagnostic tools need to be added to this, before making any diagnostic conclusions.

Scoring instructions and interpretation

Tick YES or NO for each question and then add up the number of YES responses.

Compare the totals for Autism and Attachment.

If the total for autism is high, then this is suggestive of autism.

If the total for attachment difficulties is high, then this is suggestive of

attachment difficulties.

If both are high, it is suggestive of both autism and attachment.

Name of child:

Date of birth:

Date of interview:

Name of interviewees:

Interviewer:

70 GAP,18,1, 2017
 The Coventry Grid Interview (CGI): exploring autism and attachment difficulties

Category and question ASD Attachment Comments box

Routine

1 Do they have problems with ASD: YES ATT: NO

birthdays and Christmas Score 1
and find it hard to share the
excitement?

2 Do they get distressed, or avoid ASD: NO ATT: YES

anniversaries of life events times Score 1
such as Christmas, possibly
because of difficult memories
(as opposed to the social and
sensory overload of gatherings
and the change in routine)?

3 Does everything tend to revolve ASD: YES ATT: NO

around his or her special Score 1
interests?

Difficulties with eating

4 Is food restricted by texture or ASD: YES ATT: NO

colour? Score 1

5 Is restricted diet about ASD: YES ATT: NO

maintaining sameness? Score 1

6 Does your child hoard food or ASD: NO ATT: YES

binge eat? Score 1

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Language

7 Does your child use language ASD: YES ATT: NO

repetitively? Score 1

8 Does your child use made up ASD: YES ATT: NO

words? Score 1

9 Does your child have overly ASD: YES ATT: NO

formal or stilted language? Score 1

10 Does your child over use ‘stock’ ASD: YES ATT: NO

phrases or words (eg basically, Score 1
actually, or phrases from the
TV?)

11 Does your child say things to ASD: NO ATT: YES

shock/ for a reaction? Score 1

Treasured objects

12 Does your child try to make ASD: NO ATT: YES

others approve of, or envy his/ Score 1
her possessions?

13 Does s/he deliberately destroy ASD: NO ATT: YES

treasured objects when angry? Score 1

14 When given a new toy, does s/he ASD: YES ATT: NO

still favour old toys? Score 1

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Play

15 Does your child collect and ASD: YES ATT: NO

order/arrange particular toys or Score 1
objects?

16 Does your child prefer to play ASD: YES ATT: NO

alone? Score 1

17 Does your child play ASD: YES ATT: NO

mechanically with toys rather Score 1
than creating stories about them
(eg lining up and ordering?)

18 Does your child play dramatic ASD: NO ATT: YES

or traumatic games which Score 1
may mirror things that have
happened in their own lives?

19 Does your child play with ASD: YES ATT: NO

unusual things? Score 1

20 Does your child play a limited ASD: YES ATT: NO

range of activities? Score 1

21 Can your child take on different ASD: NO ATT: YES

roles in pretend play? (although Score 1
some
females
can)

22 Does your child struggle to end ASD: NO ATT: YES

role play games? Score 1

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Social Interaction

23 Does your child seek to provoke ASD: NO ATT: YES

strong emotional reactions in Score 1
others?

24 Does your child show an ASD: NO ATT: YES

awareness of his/ her own role in Score 1
interactions?

25 Does your child struggle to ASD: YES ATT: NO

understand how interactions with Score 1
teachers may be different from
interactions with friends/peers?

26 Does your child show less of an ASD: YES a) ATT: NO

awareness to share than you Score 1
would expect for his/ her age?

27 Are they aware but too anxious ASD: NO ATT: YES

to share, and so hoard Score 1
possessions?

28 Does your child steal or take ASD: NO ATT: YES

things to hoard? Score 1

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Mind reading

29 Does s/he refer to other people’s ASD: NO ATT: YES

views and feelings? Score 1

30 Does s/he think you know about ASD: YES ATT: NO

situations when you have not Score 1
been present?

31 Is s/he aware of the types of ASD: NO ATT: YES

information you are interested to Score 1
hear about (eg what went well at
school today)?

32 Does your child exaggerate ASD: NO ATT: YES

and elaborate stories? NB female Score 1
ASD can
have elaborate
fantasy worlds
into which
they retreat

33 Is s/he hypervigilant to ASD: NO ATT: YES

others’ feelings and actions, Score 1
especially anger?

34 Does s/he ever find it hard to ASD: YES ATT : NO

distinguish fact from fiction? Score 1 (Unless
related only
to threats)

35 Does s/he often tell ASD: NO ATT: YES

sophisticated lies Score 1

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Communication

36 Does your child seek to get their ASD: NO ATT: YES

needs met by making loud or Score 1
unusual noises for attention?

37 Does s/he give detail in pedantic ASD: YES ATT: NO

fashion and give excessive Score 1
detail?

38 Does she have a poor ASD: YES ATT: NO

awareness of others in a Score 1
conversation?

39 Does he/she understand jokes ASD: NO ATT: YES

and sarcasm? Score 1

40 Does he/she seem overly ASD: NO ATT: YES

sensitive to tone of voice? Score 1

41 Does your child worry his/her ASD: NO – ATT: YES

needs won’t be met if you are Score 1
running late for them?

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Executive functioning

42 Does waiting have an emotional ASD: NO ATT: YES

significance? (eg do they relate Score 1
waiting to neglect or to having
or losing emotional control over
someone?)

43 Does waiting upset your child ASD: YES ATT: NO

because it upsets their routine? Score 1

44 Does s/he dislike getting a hug ASD: YES ATT: NO

from another person when s/he Score 1
as not initiated this?

45 Does the child seem unaware of ASD: YES ATT: NO

personal space? Score 1

Sensory

While children and young people with attachment difficulties often present with sensory processing issues, these
are often more trauma related. These questions attempt to distinguish trauma related sensory processing issues
from ASD type sensory issues. It is important that the CGI is only used at the end of a full multi disciplinary Stage
2 assessment which includes a full family, educational and developmental history and autism specific diagnostic
tools (eg ADOS and ADI). If the CGI identifies many sensory processing issues, the young person should be
referred to an Occupational Therapist for a full sensory processing assessment.

46 Pain/temperature threshold ASD: YES ATT: NO

Score 1
Is your child’s awareness of hot
and cold or pain unusual?

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Eating

47 Does your child seek or avoid ASD: YES ATT: NO

particular foods or textures? Score 1

48 Does your child use food to ASD: NO ATT: YES

self-soothe or comfort? Score 1

49 Does your child use food to ASD: NO ATT: YES

control, hoard, or create an Score 1
emotional response from
key figures?

Motor

50 Does your child tend to ASD: YES ATT: NO

bump into things, spill Score 1
drinks or trip over?

51 Is your child able to learn ASD: NO ATT: YES

new motor skills easily? Score 1
(eg ride a bike, swim)

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Movement

52 Does your child seek or avoid ASD: YES ATT: NO

movement but not recognise the Score 1
associated dangers involved?

53 Does your child intentionally ASD: NO ATT: YES

seek out risk through movement?
Score 1

54 Does your child swing between ASD: YES ATT: NO

over and under activity Score 1
throughout the day?

Tactile

55 Does your child seek or avoid ASD: YES ATT: NO

exploring through touch?
Score 1

56 Does your child seek deep ASD: YES ATT: NO

pressure (eg firm hugs?)
Score 1

57 Is your child overly sensitive to ASD: YES ATT: NO

texture of clothing (eg labels in
clothing, seams?) Score 1

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Auditory

58 Is your child unable to filter ASD: YES ATT: NO

out sounds so that it impairs Score 1
their function with every day
activities (eg noises outside;
conversations; hum of
machines ?)

59 Is your child more hypervigilant ASD: NO ATT: YES

to sounds associated with a Score 1
previous trauma?

Visual

60 Is your child often seeking or ASD: YES ATT: NO

avoiding visual stimuli? (eg Score 1
wearing sunglasses, seeking
patterns, lining up coloured
pencils or engaging in finger
movements in front of their eyes)

61 Does your child scan the ASD: NO ATT: YES

environment and seek and Score 1
recall information essential for
maintaining their safety?

Smell

62 Does your child seek or avoid ASD: YES ATT: NO

smells (eg sniffing food before Score 1
eating it?)

63 Is your child reactive to smells ASD: NO ATT: YES

associated with key attachment Score 1
figures or key events?

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