Could My Adopted Child Have an Attachment Disorder?

Caught up in the considerable effort it takes to find a child to adopt, many adoptive parents who choose to adopt toddlers and older children forget that one day a child will actually come to live in their home. It's not surprising then that the unmitigated joy they expect to feel can give rise to panic. Whether the new addition to the family is a quiet six-year-old from Russia or a rambunctious two-year old from foster care, parents may be unprepared for the day-to-day realities of raising a child who does not, after all, come with a set of instructions.

Like most parents, adoptive parents often seek advice about child development to help them cope. And before long they inevitably come across a welter of information (and misinformation) about RAD (Reactive Attachment Disorder), attachment disorders and attachment therapy.

If you are wondering what these terms mean, you are hardly alone. RAD is the only one listed in DSM-IV, The Diagnostic and Statistical Manual used by social workers, psychologists, and psychiatrists to provide diagnoses. An "attachment disorder" is not an agreed-upon diagnostic entity but is often used to describe the difficulties of children who have had multiple caregivers or very little contact with caregivers while in orphanages and foster care. It's helpful to look at attachment on a continuum, with healthy attachment on one end, RAD on the other, and various attachment issues in between.

With some understanding of attachment theory you, the adoptive or pre-adoptive parent, can help your child avoid getting an inappropriate label and/or the wrong type of treatment, which can, in fact, be harmful.

The core feature of RAD is severely inappropriate social relating that begins before age 5. There are two basic types of RAD: One is characterized by the child's indiscriminate and excessive attempts to get comfort and affection from any available adult-even relative strangers. The other is characterized by extreme reluctance to initiate or accept comfort and affection from known adults. Some of the disorders and syndromes that may be mistaken for RAD include ADHD (attention deficit/hyperactivity disorder), a conduct disorder, PTSD (post-traumatic stress disorder), autism, an adjustment disorder, and childhood schizophrenia.

Attachment theory got its start in the 1950s. One of its earliest proponents, John Bowlby, studied the patterns of relating between babies and their mothers (or other primary caregivers) in the 50s and 60s. He believed that infants and mothers learned to relate to each other in a way that ensured their survival, as well as the survival of the species, and that difficulties in attachment set the stage for social and emotional problems later in life.

According to Bowlby attachment develops through encounters between a mother and her baby. A baby cries because he is hungry, wet or otherwise miserable, and the mother responds by feeding, changing or holding the baby until he calms down. These encounters occur thousands of times over the course of a baby's young life, and he comes to experience the world as a safe and predictable place where his needs can be met. And because they are met, his energy is available for the fundamental tasks of childhood: exploring the world and developing a sense of mastery.

The above best-case scenario is rarely something that a toddler from foster care has experienced. After all, most foster children are taken from their parents due to abuse and/or neglect. A foster child may experience some good parenting, but most probably it has been erratic. Still, this child has been related to as a person by his mother or foster mother(s) at least some of the time. Later on, he may exhibit symptoms of what we have come to call attachment disorders.

The attachment capability of a child adopted internationally from an orphanage can be more compromised. Says Miriam Steele, PhD, a professor at The New School for Social Research in New York City and an expert on attachment, "When you think about how these vulnerable infants and children are cared for, in situations where there isn't a caregiver specifically assigned to care for one, two, or even three children with whom they feel connected, it is difficult to comprehend how this child-rearing could be comparable to what most other infants experience growing up in some kind of family home."

Whether you are adopting a child from an orphanage or from foster care, it's a good idea to get all the details you can on your child's relationships with his caregiver(s). This will help you begin to understand the child you bring home. The first few days of a child's life in your family is not a good time to start evaluating his ability to attach. He will be adjusting to having parents-possibly for the first time in his life-as well as to the sights, sounds, and smells of his new home. Your job as an adoptive parent is, at this moment, to create the stable, safe, loving and predictable environment your child needs in order to begin to feel comfortable.

What if things are not, after a matter of weeks, moving toward a positive relationship between you and your child? You will want to begin looking for a therapist who can help you. Look for a trained, licensed mental health professional with expertise in both child development and differential diagnosis. Dr. Miriam Steele says, "RAD in its 'pure form' is relatively rare, and it occurs most often in children who spent their early months or years in institutional settings characterized by severe deprivation. Your child may exhibit behaviors that are indicative of attachment difficulties in milder forms, but which still require careful attention and support to help get you back on track to a more satisfying way of relating for you and your child."

A good assessment and diagnosis requires an understanding of your child's long-term behavior in multiple settings. The therapist will want to know how your child is doing at home and at school. Ideally, an evaluation should not be done while your child is under stress because stress can cloud a diagnosis. This could be reason enough to hold off for a while. (If your child is in significant distress, though, you will need to engage a professional sooner.) In the meantime, you can consider seeing a therapist yourself to get the guidance and support you need.

Sometimes it also makes sense to get a specialized assessment by a second professional who is an expert on a disorder your first mental health professional suspects your child has, i.e., someone who specializes in ADHD or PTSD. This may sound like a lot of work, but it is worth it to get the right diagnosis for your child, so that valuable time is not wasted treating a condition he doesn't have.

What type of therapy is your child likely to need? The authors of the American Professional Society on the Abuse of Children's 2006 Task Force Report* tell us that therapy based on traditional attachment theory should be the first-line of treatment. The focus should be on giving the child a stable environment and increasing the positive quality of the parent-child relationship and interactions. Focused, goal-directed, behavioral approaches should be taken, and parents should be involved in the process.

You need to be especially vigilant to stay away from controversial therapies that, confusingly, refer to themselves as "attachment therapy." In fact, they have little to do with attachment theory or attachment research and can be very harmful. (Children have died from some of the treatments they employ.) These therapies, which have not been adequately tested, emphasize the child's resistance to attachment and the need to break down that resistance. The focus is on the child's pathology, especially his rage. The therapist may control a child's fluid and food intake as well as his bathroom privileges or physically have him make eye contact, as if this in and of itself would be helpful in establishing an attachment relationship. The goal can be to have the child go through a "rebirthing" process or be the recipient of "holding" therapies. Many of these therapies promise "quick fixes" and they capitalize on adoptive parents' anxiety by marketing to them directly.

Instead, take small, but deliberate steps to get help for you and your child. Join a support group composed of parents who have adopted from abroad or through foster care. Acknowledge that it may take time, but that you have the power to help your child move to the healthier side of the attachment continuum. Recognize that you will be filling in some of the gaps in his attachment experience, by committing yourself to being the best parent you can be one day at a time.

John Bowlby offers some encouraging words in "A Secure Base" (1988): Although the capacity for developmental change diminishes with age, change continues throughout the life cycle so that changes for better or for worse are always possible. It is this continuing potential for change which means that at no time of life is a person impermeable to favorable influences."

*Read this for a more detailed look at many of the points in this article: "Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems," in Child Maltreatment, Vol. 11, No. 1, February 2006, pp. 76-79.

Carolyn Berger, LCSW, is the Adoption Coordinator of The AFA. She has two teenage sons. Her second son joined the family through adoption.