I recently subscribed to an on-line chat group of adoption professionals from all over the country. Topics discussed range from clinical to recruitment issues. A recent posting caused quite a stir. Someone posted a request from a family who wanted to disrupt the adoption of their three-year-old son, whom they had adopted from an orphanage in Eastern Europe. The child was described as cute, funny, charming but high needs, hard to parent and as having Reactive Attachment Disorder. Multiple responses ensued and everyone had an opinion about the situation; but it was not the fact that an adoption of a very young child was about to disrupt that got everyone up in arms -- it was the use of the term Reactive Attachment Disorder.

According the DSM IV, the diagnostic criteria for 313.89 Reactive Attachment Disorder of Infancy and Early Childhood are (paraphrased):

1. Markedly disturbed social relations, beginning before the age of five, as evidenced by either:
   • persistent failure to initiate or respond to most social interaction
   • indiscriminate sociability
2. The disturbance in (1) is not a symptom of Mental Retardation or Pervasive Developmental Disorder.
3. Grossly pathogenic care, as evidenced by at least one of the following:
   • persistent disregard of the child's basic emotional needs
   • persistent disregard of the child's basic physical needs
   • repeated change in primary care giver, so that stable attachments are not possible
4. There is a presumption that the care provided in (3) is responsible for the behavior seen in (1).

Symptoms that are commonly seen in children with attachment disorders are:

• Lack of eye contact.
• Superficially engaging, charming or phony.
• Inability to give and receive affection on caregivers' terms.
• Indiscriminate affection toward strangers.
• Chronic lying, even about the obvious.
• Poor impulse control.
• Destructive and aggressive behaviors toward self and others.
• Poor peer relations.
• Extreme control problems (manipulative, sneaky, demanding, clingy).
• Speech problems or delays.
• Preoccupation with blood, gore, and fire.
• Over-reaction to small hurts, but no reaction to larger, emotional hurts.
• Lack of conscience and remorse.

There are multiple factors that can lead to attachment difficulties; if a child experiences one or more during the first three years of life, there is a greater risk for serious damage. In general, if an infant's needs are not met consistently in a loving, nurturing way, normal attachment does not occur. Risk factors include:

• Maternal ambivalence toward pregnancy.
• In-utero exposure to drugs, trauma or alcohol.
• Neglect of emotional and/or physical needs.
• Abuse (physical, sexual, emotional).
• Frequent moves or placements (foster, hospital, adoption).
• Sudden separation from caregivers.
• Undiagnosed or painful illness in the child.
• Unprepared/Unresponsive parent
• Inconsistent or inadequate care and or daycare

When an infant's needs are not met, they learn that the world is an unreliable place where they can depend on no one but themselves to meet their needs. Children with attachment disorders are unable to love or trust others, especially caregivers, and may actually feel that they will die if they give up their control. They become adept at getting their needs met by being charming, sneaky, manipulative- they are masters at surviving in an unpredictable world. While most of us learn to trust caregivers during our first year of life, children who do not have their needs met develop feelings of helplessness, hopelessness and anger. These feelings are internalized, and at the core of every child with an attachment disorder is an unresolved, deep-seated rage.

Many of the behavioral symptoms of Reactive Attachment Disorder are similar to those seen in children with Attention Deficit Disorder with Hyperactivity, Oppositional Defiant, Post Traumatic Stress and Conduct disorders, as well as those with severe depression. Many children who have Reactive Attachment Disorder are incorrectly diagnosed as having some sort of other disorder where similar behaviors are present. It is therefore very important for families to get an accurate diagnosis for their child from an experienced, trained professional.

There are some professionals who feel that Reactive Attachment Disorder is an overused label placed on children from the system who are challenging to parent. In truth, the number of children diagnosed with Reactive Attachment Disorder has increased in recent years.

However, to many families, and the professionals who work with them, Reactive Attachment Disorder is an all too real condition that can rip families apart. To help these families cope with the challenges of parenting a child who does not want to be parented, and to prepare families who may be considering adopting or fostering a child with Reactive Attachment Disorder, professionals and experienced families have many tips:

• Remember that it takes more than love and good intentions to "save" these children, but that with proper therapy, support, commitment and time- most children can learn to attach.
• Take care of yourself! Parenting is tough work, especially with children who do not respond to or fight your best efforts. Don't take a child's behavior personally. Make sure you get regular time to yourself and with the rest of your family. Respite will be a must. Also remember that parenting a challenging child can bring up any unresolved issues about the way you were raised. This may add to already high emotions.
• Children with Reactive Attachment Disorder are adept at triangulation. They may present themselves and interact with one parent as "a little angel" and be the opposite with the other. It is essential that parents act as a team. Children with RAD can sense "weakness" and will manipulate a divided front to their advantage.
• Most children with Reactive Attachment Disorder are also quite skilled at lying about everything, including the obvious. Don't believe everything the child says. Investigate their story with others who were there- teachers, schoolmates, siblings, other adults, and discern the truth from there
• There are several environmental factors that lend themselves the successful healing of a child with reactive attachment disorder. These include a stay at home mom, a supportive partner, the child being the youngest or only in the family, and no other children with attachments disorder in the family setting.
• Challenging children take creative, determined and committed parents. Children with Reactive Attachment Disorder tend to respond best to a structured environment where there are clear expectations and consequences for unacceptable behavior. Love and Logic style-parenting techniques, which hold children accountable for their actions, are often cited by parents as essential. Additionally, therapy will be a must for both the family and the child. The goal of therapy will be to help the child bond to parents and to resolve the child's fear of being loved and getting emotionally close to others. In most cases this will involve regressive therapeutic techniques that allow the child to work through the trust issues that developed during infancy and begin the bonding process to caregivers.
• Education! Knowledge is power and offers families the opportunity to realize that their child has a real psychological condition, possible treatment and parenting options and resources available to them. There are plenty of books, articles, workshops and internet sites about RAD available to families. Equally important is the education of those in the community who may come in contact with the child or family. Extended family, teachers, doctors, therapists, local protective service workers and police officers may not have heard of Reactive Attachment Disorder. They may only see the see the "angelic" side of the child, and view the family as rigid, inflexible and abusive. Families need to be able to work with others as a team.

Eventually, a new adoptive home was located for the cute but challenging three-year-old. This family was well prepared for his behaviors, had a good resource network and was aware that it may take months or years for this youngster to learn to get close to them. But their philosophy reflects the words of Helen Keller, a survivor of Reactive Attachment Disorder herself, "Believe, when you are most unhappy, that there is something for you to do in this world. So long as you can sweeten another's pain, life is not in vain."

Reactive Attachment Disorder Resources

There are numerous resources available to families and professionals who want to learn more about attachment disorders or parenting. The following are available through the MARE lending library:

National Adoption Information Clearinghouse (NAIC), Attachment Disorder: Resources for Professionals (a bibliography)

Foster Cline and Cathy Helding, Can This Child Be Saved? Solutions for Adoptive and Foster Families

Richard Delaney and Frank Kunstal, Troubled Transplants: Unconventional Strategies for Helping Disturbed Foster and Adopted Children

Ken Magid and Carole McKelvey, High Risk: Children Without a Conscience

Gregory Keck and Regina Kupecky, Adopting The Hurt Child: Hope for Families with Special Needs Kids

Richard Delaney, Raising Cain: Caring for Troubled Youngsters/Repairing Our Troubled System

Nancy Newton Verrier, The Primal Wound: Understanding the Adopted Child

Foster Cline and Jim Fay, Parenting With Love and Logic

Other resources not in the MARE library, but are usually available through Tapestry Books:

Robert Karen, Becoming Attached

Martha Welch, Holding Time

Daniel Hughes, Building the Bonds of Attachment

Terry Levy and Michael Orlans, Attachment Trauma and Healing

Carole McKelvey, Give Them Roots, Let Them Fly

Beverly James, Handbook For Treatment of Attachment: Trauma Problems in Children

Elizabeth Randolph, Children Who Shock and Surprise: A Guide to Attachment Disorders

There is also plenty of good information and sites on the internet pertaining to Reactive Attachment Disorder. Just do a search on Reactive Attachment Disorder, or Attachment Disorders.