RAD-Reactive Attachement Disorder article

Why Chinese Adopted Childen Are at Risk for RAD
Part I: Secure Attachment and Reactive Attachment Disorder

It is important for adoptive families to recognize how a child's early experiences can impact their future emotional development. Children adopted from China have experienced the loss of their birthmothers, physical abandonment, and multiple caretakers. Most have suffered deprivation and/or neglect in varying degrees. Some have endured physical and/or sexual abuse. These conditions interfere with the capacity to form secure attachments.

Secure attachment forms when a child's physical and emotional needs are consistently met during the first 2 years of life. Because she trusts that her parent will be there, she will internalize an image of her world as safe, stable, and dependable. She will develop independence while at the same time maintaining a connection with her parents. She will learn to engage in mutually enjoyable interactions where the interaction itself is the end goal.

Reactive Attachment Disorder (RAD) is any disruption in attachment resulting in a child's failure to form a SECURE bond/attachment with a parental figure. Secure Attachment and Reactive Attachment Disorder are best understood as a continuum. The most securely attached people are confident, high functioning individuals with a strong sense of self worth, highly developed empathy and the ability to engage in healthy, mutually enhancing relationships, both within and beyond their immediate families. The most unattached people are violent psychopaths, people without empathy or conscience, unable to relate to others except as objects to meet their needs.

Reactive Attachment Disorder includes the whole spectrum of children with symptoms ranging from mild to moderate to severe. Therefore, a child can be "attached" and still have RAD. Having 'attachment issues' or RAD does not mean your child doesn't love you. It does not mean that the adoptive parent is a poor or unloving parent. Nor does it mean that the child is of low intelligence or developmentally delayed. What it means is that the child's brain has been programmed to protect her from pain, thus preventing her from giving and receiving love. The child will need specific treatment to learn how to do this, just as she might need specific therapy to overcome any illness.

Scientific research has indicated that the bond between mother and child begins to form even while in the womb, so that at birth a child can recognize it's mother's voice and smell. Even a child who was abandoned at birth and subsequently received good care could experience the loss of her birthmother as traumatic.

Most Chinese adoptees are subjected to additional experiences that heighten their risk for RAD. If a mother knows that she may not be able to keep her baby, the child can experience rejection while still in the womb. The mother may risk her life giving birth in an unhealthy/unsafe place. Children might experience birth trauma due to inadequate medical care. There are women who want to keep their children but are under pressure from family or authorities to give them up. These children could be kept hidden, and not given proper care and love for an extended period prior to abandonment.

Even the best orphanages are unable to simulate the care and attention a child would receive in a family. Normally, babies go through the bonding cycle thousands of times during the first three years of life. When the baby is hungry, wet, cold or wants to be held, she becomes aroused. She feels angry or upset and cries. When that need is met, the baby feels gratification, and develops trust. Each time that cycle is disrupted, the baby feels helpless and angry and does not learn to trust.

Babies in orphanages often spend entire days lying in a crib, cold and wet. They are cared for on a schedule determined by the availability of orphanage staff. If bottles are propped, they will not associate being fed with human contact and warmth. Cries of distress can go unheeded for hours. After awhile, children fail to recognize their own body signals. Their feelings of need become so painful they shut them off. Even if their physical needs are met, they do not learn the joy that comes simply from engaging with another human being or the comfort that comes from having their upsets soothed by loving hands. They lack physical contact in a loving embrace. Infants who are not touched can develop failure to thrive.

Abandoned children who are not strong and tough die. Those that live, learn survival skills that are appropriate for an institution, but which may inhibit attachment within a family. Even foster care has its risks. Some foster parents are abusive and neglectful and are motivated more by the income than love. Some foster parents have several babies to care for. Many are poor and illiterate. Even children in good placements experience the original abandonment of their birthparents and then subsequent loss of their foster parents.

In Chinese adoption there is no gradual transition, no time to prepare for new situations or to mourn the loss of the old. Older children who might understand the process are not always prepared or honestly informed of what will happen to them. When their 'orphanage friends' are adopted, they see them disappear forever (causing further loss for the child who remains at the orphanage.) When adopted, the child is suddenly whisked away from everything familiar. To be placed in the hands of strangers can be terrifying. Americans who speak an unknown language, look, smell, eat and behave differently, also have different expectations. This experience mirrors their original abandonment where one moment they are in their mother's arms and the next moment mother is gone, and their life is dependent on strangers. Once they board the airplane, everything familiar disappears. No matter how hard they cry, the mother, or caregivers, or foster parents do not return. Thus, the act of adoption, while seemingly happy for the adoptive parents, can be perceived by the adoptee as a re-play of her initial abandonment.

It is not uncommon for Chinese adopted children to suffer from developmental delays and/or regulatory disorders. Patterns of behavior and symptoms can fall into many overlapping categories -- Post Traumatic Stress Disorder (PTSD), Sensory Integration Disorder (SID), Attention Deficit, Hyperactivity Disorder (ADD & ADHD), Oppositional Defiant Disorder (ODD), Pervasive Developmental Disorder (PDD), Autism, Grief, speech & language impairment, learning disabilities.

All of these regulatory and language disorders can exist on their own without RAD, or they can coexist with RAD. For instance, SID can be created by the same conditions (deprivation and neglect) that cause RAD, but is still a separate diagnosis. However, there is always some component of grief, loss and trauma in every child who has RAD. Trauma and RAD can also create symptoms that mimic many of these disorders (such as ADHD or PDD), as well other psychiatric disorders not mentioned above. It is important for parents to recognize that this overlap in symptoms makes getting a proper diagnosis and appropriate treatment confusing.

Any of these disorders can also interfere with the formation of secure attachment, even after the child is living in a safe environment. A grieving child may feel she is being disloyal to previous parents or caretakers if she allows herself to love her new parents. She may be too frightened of loss to risk loving again. Or too angry to let any other feelings in. Similarly, a traumatized child may find it impossible to trust that her new parents won't hurt or leave her. She may withdraw from touch or any kind of interaction initiated by them. Physiologically and emotionally, she may still be living in a state of inner terror. A child with SID, who is highly sensitive to touch, may reject and arch away from her parent's embrace. Language disorders interfere with a child's ability to communicate her needs and feelings. All these conditions may cause a child to engage in behaviors which new parents find distancing or frightening.


Part II: The RAD Continuum

We will identify three levels of attachment disorder. These descriptions merely illustrate the emotional logic behind different presentations of RAD. The pattern of symptoms is unique for each child. In addition, symptoms can overlap, and change as children develop and incorporate their current life experiences into past patterns of response.

Level One: The child is able to "attach" or "bond" with the adoptive parent in the sense that she recognizes the parent as the person she "belongs" to, but the quality of "trust" is lacking. She may "love" the parent, but does not allow or rely on the parent to meet her needs or to keep her safe. She doesn't understand the concept of permanence, and that she will forever remain with her adoptive mother.

This child may be overly clingy and/or suffer from severe separation anxiety. She panics when not physically (or visually) connected to the parent. She may be overly fearful of and/or have difficulty socializing with adults or children outside her family. She may exhibit controlling behavior in an attempt to maintain contact with the parent at all costs and to ensure that her needs will be met. She may be hyper-vigilant, ever on the alert for impending loss or hurt. Or she may be the "overly good" child, fearful lest she make a mistake and be abandoned again. She may also be a child who appears on the surface to have made a good adjustment and attachment to her family. She conforms to family rules and expectations, but is merely acting the part that she perceives has been given her in order to maintain her place in the family. She may be suppressing her true self and feelings because she does not believe they would be accepted.

Level Two: The child "wants" attachment/connection, but, because she is afraid that the parent might leave her, hurt her and/or not meet her needs, she "chooses" to control the terms of the attachment. In order to protect herself from the pain, grief and loss she believes is inherent with attachment, she rejects or withdraws from the relationship, especially when closeness is initiated by the parents. These distancing behaviors may be alternated with intense clingyness.

What differentiates this child from level one is the presence and/or intensity of her distancing behaviors. The child erects a wall between herself and her parents. She may be defiant and oppositional, expressing her rage directly at her parents. She may be charming and friendly to strangers. She may prefer dad to mom. She may refuse to be held or she may express affection on her terms only. She may have difficulty making eye contact, especially during times of intimacy or distress. She may be withdrawn, even to the point of exhibiting autistic spectrum behaviors. She may lack imitative behavior, pretend not to understand, and communicate only on her own terms. She may have difficulty acknowledging "good-bye" and/or "hello". However, despite the distancing behaviors, she can -- often in very subtle ways -- reveal that the connection to the parent does matter to her. For example, she may get busy and pretend not to care when her parent leaves for the day, but the very act of changing her behavior is an indication that the parent's departure does matter. What differentiates her from the child in level three, is that she is still aware, on at least some level, that she wants and needs connection.

Parents should recognize that these behaviors are a cry for help. For example, the child does love the mother, and wants to be loved back, but because of the defensive mechanisms developed to protect herself from pain, she is unable to seek connection in appropriate ways. She does not have the problem-solving skills that would allow her to effectively communicate her conflicted feelings. Instead, her insecurities manifest themselves in abnormal behaviors that are misinterpreted. (i.e. Mommy, I was so scared when I woke up in the train station and my birth mother was gone, that now I'm afraid of losing you too. That's why I tore up my favorite book, or peed on the carpet, or some other indirect, aggressive act, when you went to the store without me.) (Mother thought she was just being naughty.) Parents need to be aware of the warning signs in order to reach out for their hurting children. It is not the adoptive parent's fault that their children behave the way they do.

Level Three: "Classic" RAD / "institutional autism" This child has given up and shut down. Connection/attachment is no longer a motivating life force. People are seen as interchangeable objects, existing only to serve the child. Her wall of defenses prevent her from reciprocal interaction with the human community.

These are the children who receive negative media attention. Their behavior is extreme. They may be physically destructive and violent in their families: destroying property, attacking parents and hurting younger siblings or animals. Because they never experienced empathy, they failed to develop a conscience. They are often bright and superficially charming, but lack inner depth. Other people don't matter.

This third degree of RAD is not common in Chinese adoptees because most of them are too young at placement for it to have developed this far. However, if left untreated, it is possible for children initially in level 1 or 2 to move into level 3 as they grow up.

Also in level 3 are the children who fail to 'catch up' once living in their adoptive homes. They can have severe language delays, SID issues and self-stimulating , repetitive and/or ritualistic behaviors. They may be misdiagnosed with Pervasive Developmental Disorder or Autism. Because these other syndromes produce behaviors that are difficult to differentiate from RAD, many parents spend a great deal of time seeking proper diagnosis and treatment, not knowing what lies at the core of their child's problems.


Part III: Healing and Treatment

RAD is inextricably intertwined with trauma, separation and loss. Anger, fear, grief and shame are the dominant emotions that drive RAD children. One emotion is usually more "tolerable" for the child to experience, and this emotion serves as a barrier to feeling the others; i.e. high levels of anger or fear will prevent the child from feeling grief and shame. In order to process grief and shame she first has to get through the anger/fear. The far end of anger would be an "anti-social" child. The far end of fear would be a child who has withdrawn into autistic-like behaviors. The symptoms we see in our children reflect the way they have internalized their individual experiences.

Shame is the most difficult emotion for a child to uncover and process. It lies at the core of her inability to attach. The most shameful thing an infant can experience is not being loved. An infant is supposed to experience herself as the center of the universe. It isn't until a child is much older that she can understand the political/cultural motives behind abandonment. The only way she can interpret it is that she was thrown away because she was bad/ deficient/ unworthy etc. This sense of shame is then heightened by the neglect and deprivation that usually follows in the orphanage. Not only was she unwanted in her birth family, but for a long time no one else wanted or cared for her either.

Thus, the child may develop a core self that is built around shame. She believes everything is her fault, even when it isn't, and that she is an intrinsically bad person who deserves nothing. Every "mistake" she makes is experienced as an assault to her being, a confirmation of her worthlessness and badness. To protect herself from this shame she erects a barrier of rage or terror. It is this shame that lies at the root of her inability to trust, to let in love -- and to change her behavior.

For treatment to be effective, it must ultimately release shameful feelings and help the child separate herself from her actions. So, when she makes a mistake, instead of internalizing that she is not a good girl, she will feel that she is a good girl who just made a mistake, and it's not so devastating.

Most attachment experts agree that traditional therapies such as play therapy do not work. This is because RAD interferes with the child's ability to form an emotional connection with the therapist, which is a prerequisite for success. To complicate the picture, early childhood trauma and memories are stored in the limbic portion of the brain - an area not connected to speech and language centers. These memories are stored as emotions, sensations (sounds, images, smells) and body memories (muscular tensions that can trigger emotional reactions). Traumatized children lack the ability to access these memories through verbal expression.

For RAD children, healing must begin by re-creating the mother/child regulatory bond. The child needs to regress through early stages of infancy to recreate the experience of healthy nurturing which she missed as a baby. She must learn to depend on her parents to care for her, comfort her and meet her needs. Only then will she learn to trust others. Helping your child attach words to her feelings and memories -- as well as to her present safety -- will also help her to organize and make sense out of her experience.

As part of the healing process, the child needs to express her terror, rage, grief and shame, and have these feelings accepted and validated by her adoptive mother. What happened to her was truly terrible. These buried feelings are a part of her experience and therefore a part of who she is -- just as much as her Chinese cultural heritage is a part of who she is. If these feelings are deemed unacceptable, denied, unrecognized, or ignored, then she will feel unacceptable and invisible in her deepest core self. Her feelings will go underground and will re-emerge later in life, being all the more powerful for having been repressed for so long.

However, to simply re-live or express these feelings by themselves is merely re-traumatizing. In order to heal, emotional and body memories must be re-experienced at high intensities in a theraputic setting. By re-living past trauma in the loving physical embrace of her new parents the child will learn that a different outcome is possible. She will feel safe enough to explore the world in a loving, reciprocal way. Only then will she be able to move beyond her past to become a whole human being.
© 2000, all rights reserved. Written by Laura Beck, MSW, Nancy D'Antonio, Lynne Lyon. May not be reproduced in any form without written permission of the authors.