Attachment disorder: are we trying to fit square pegs into the round holes?
One of the most burning questions for the adoptive parents during a pre-adoption consultation or initial post-adoption screening or assessment is a possibility of attachment issues in the internationally adopted children. Many adoptive parents, following the wide-spread opinions of different experts in the field, are sure that all post-institutionalized (PI) children, even those adopted as infants, will come home with at least some degree of attachment problem. This is still a very controversial issue.
According to contemporary understanding, attachment is formed when a specific caretaker responds in an effective and timely manner to the baby's needs. When there is a break in relationship with the primary caregiver, this can lead to attachment difficulties. Because of the nature of any orphanage, the children's needs have not been met in an effective and timely manner; the orphanage residents were not given the opportunity to form a healthy relationship with a primary caregiver. Therefore, theoretically none of internationally adopted PI children come to adoptive home with readiness for secure attachment.
We know that attachment disorders (AD), as practically all psychological functions and states, may be spread from severe to mild, from an incurable profound disorder to practically non-existent or very mild condition. Indeed, there are PI children, who are so damaged that when adopted, they are completely unable to make any kind of connection to a primary caretaker. And there are some who bond instantly and forever. But most of the time, the issues are somewhere in-between: it's a question of degrees. Basically, attachment is the core of the adoption: without some degree of attachment no adoption is destined to survive. Its a real issue that many adoptive families are facing and struggling with.
Saying that, I have to admit that AD is likely to be over-diagnosed in international adoption community. AD is often confused with the normal process of initial adjustment and re-adjustment in the family; AD symptoms are often confused with neurologically-based disorders or different psychiatric conditions; and, finally, AD symptoms are often mixed up with learned post-institutionalized behavior.
Attachment is a process with many individual differences: every child and every parent will have some adjustments to make in the bonding process. The adjustments will vary as personalities differ. Adoptive parents are strangers to their children, and when they come home there may be an initial bond, but true attachment is something that forms over months and years, not in a matter of several weeks. Actually, it would be a miracle if any PI children were totally, completely attached to adoptive parents when they come home, or even within the first two or three months.
Attachment is a two-way street: a child is attaching to his adoptive family and an adoptive family (and each member of it individually) is attaching to a child. Again, AD is a reciprocal process, and it is unfair to place a burden on the child and prescribe inappropriate treatments that focus on forcing the child to 'attach' to the new parents, rather than working on it together. With this one way approach many adoptive parents tend to look at their child suspiciously and with fear. They would tell other adults (such as family friends or teachers) to avoid being friendly with their new child (so as not to interfere with the 'bonding' they are trying to accelerate). As Dr. Morford writes, some children survive institution, only to be emotionally assaulted by parents who are focusing on their own emotional needs, rather than the child's.
There are, of course, some extreme cases (where AD is combined with other psychiatric disorders), which must be treated in a highly specialized environment like residential facility. But this is an exception that confirms the rule: AD has to be treated by living in a family and acquiring family experience. It does not exclude an outside therapy - but the main support comes from parents.
AD, unfortunately, is often used as a catch-all term to cover a range of different behaviors. Just looking on the laundry list of symptoms attributed to AD raises the question: dont we see the same behavior patterns in ADHD, Bi-Polar, Childs Depression, or Conduct Disorder? Some professionals, particularly those specializing in AD, tend to interpret any symptom in the AD context, following the famous maxima: if your only tool is a hammer, everything becomes a nail. In my practice I had a case when a child with clearly expressed Aspergers Disorder was for two years in AD therapy without even a clue that his behaviors were defined by an autistic quality rather than inability to attach. In still another case, a girl was in different sort of AD treatment until the correct psychiatric diagnosis of Obsessive-Compulsive Disorder was established and the child was treated with proper medication. Too often a neurologically-based disorder leads to AD-like behavior and
AD therapy is a wrong way to go in this circumstances. AD has a strong learned "orphanage-induced" behavior component that must be rehabilitated in family environment. Some core symptoms of AD were adaptive and effective behaviors in orphanages but they become maladaptive and counter-productive in a new school and family. Orphanage behavior patterns are often overlooked and downplayed due to the lack of knowledge and experience with children living in foreign orphanages. They are: immature self-regulation of behavior and emotions, controlling and avoiding behavior, self-parenting, extreme attention seeking, and indiscriminate friendliness with strangers. As one can see, these behaviors fit into AD picture very tightly. Nevertheless, there is a big difference between AD and orphanage behavior, and these two conditions should be treated differently. Post orphanage behavior is not an abnormal (pathological) behavior. This is a learned adoptive reaction to an abnormal environment. By the nature of things and social norms, children are not meant to live in institutional care, and when returned into the family, they need to learn new and more appropriate and productive patterns of behavior.
Lately there were a number of cases when children, who were seemingly fine and integrated into their new families, would re-surface with the attachment issues again. Whats happening in these cases and should we put the labels on these children now? This question also does not have a straight answer. The reason that some children are just now being diagnosed with attachment issues is basically threefold. First, it may take years of slow progression toward attachment to finally realize that its not going to happen. Again, there are reasons for this to become apparent only years later: increased facility of childs language, cessation of other major life issues that complicated attachment (learning disabilities, depression, physical problems, etc.), completion of therapies, etc. The inability of the family to offer love and emotional protection long term may be a reason too. Second, the child may have hit a new milestone, or life crisis, or level of awareness, which effectively "raises the bar" so high that there is a setback within family relationships. This may be a frustration with new academic requirements that can't be easily mastered. It can be a flood of new hormones with the onset of puberty or an issue within the family that caused the child to "relive" the trauma of previous abandonment or abuse. Third explanation is that with the raised awareness and knowledge of symptoms, more and more psychologists, psychiatrists, and pediatricians will be identifying and qualifying symptoms as attachment issues and suggesting parents seek out treatment for these issues. That doesn't necessarily mean that children are suddenly unattached after years of fairly normal family dynamics. It means that families do need to "revisit" some issues that may not have been entirely resolved. All this complexity leads us to the question of prediction of AD in internationally adopted children.
Here I must repeat again and again: AD cannot be observed and AD behaviors cannot be experienced in just a few hours when visiting your adoptive child in the orphanage, or looking at video tapes or during a pre-adoption evaluation. No AD can be diagnosed in the first weeks and even months of adoption. It takes time, careful observation, and experienced professional to determine the presence of AD (in most cases as a part of other disorders, such as learning disability, ADHD, etc.) or differentiate it from other conditions with the same or similar symptoms.
Dr. Boris Gindis is a prominent child psychologist specializing in psycho-educational issues of older internationally adopted children. He is the chief psychologist at the Center for Cognitive-Developmental Assessment and Remediation (www.bgcenter.com), a lead instructor at Bgcenter Online School (www.bgcenterSchool.org), the author of many publications on international adoption issues and frequent presenter at conferences and workshops.