Helping Children With Attachment Disorder Succeed
Wednesday, May 12, 2010
We'll hear about the causes, symptoms and treatment options for attachment disorder and how parents can help children with special needs succeed.
This episode of These Days is part of KPBS' THIS EMOTIONAL LIFE outreach campaign. Funding for This Emotional Life is provided by the Corporation for Public Broadcasting and Public Television Viewers. Additional funding provided by the University of Phoenix and the Substance Abuse and Mental Health Services Administration. For more information please visit pbs.org/thisemotionallife.
MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. A 7-year-old boy, his face pixilated on the TV screen, was seen being shuttled in and out of vans in Moscow last month. The story behind the pictures was disturbing. The boy's American adoptive family had sent him back to Russia because they said his behavior was too threatening. For a brief period of time, Russia threatened to shut down all adoptions to America because of the incident. Whether or not the allegations against this little boy are true, they reinforce concerns about adopted children and a condition known as reactive attachment disorder. Some parents of children adopted internationally have reported difficulty in dealing with symptoms of attachment disorder and being completely unprepared for a child with this condition. Here to tell us more about what attachment disorder is and what adoptive parents need to know are my guests, Dr. Cheryl Rode. She is Director of Clinical Operations for the San Diego Center for Children. Dr. Rode, welcome to These Days.
DR. CHERYL RODE (Director of Clinical Operations, San Diego Center for Children): Thank you, Maureen. I’m very excited to be here today. I think it’s an important topic and a good time to talk about getting services for children in need.
CAVANAUGH: Thank you for that. And Brent Yoder is Executive Director of Adoption Options, Incorporated. Brent, welcome.
BRENT YODER (Executive Director, Adoption Options, Incorporated): Thank you very much.
CAVANAUGH: We invite our listeners to join the conversation. If you’re an adoptive parent, tell us if your child has had difficulty adapting to your family. What support should be available for kids who’ve been mistreated or abused before being adopted? Give us a call with your questions and comments. Our number is 1-888-895-5727, that’s 1-888-895-KPBS. Dr. Rode, tell us right off the bat if you could, what is attachment disorder?
DR. RODE: Could I start off by talking a little bit about what attachment is?
DR. RODE: Okay, let’s start there. So attachment is a natural process of child development. It’s a reciprocal process by which an emotional connection develops between an infant and their primary caregiver. This process of an emotional connection influences a child’s physical development, their psychological and social development, even their neuro-cognitive development, so what’s happening in the development of the brain. We think of this really as a central component to social and emotional development throughout early childhood.
CAVANAUGH: And so let me interrupt you, if I may, before we go on to the disorder. How much attachment does a child need to an adult or a caring figure and at how early an age for this to develop normally?
DR. RODE: Sure. In healthy development, it occurs all throughout the first year of life, the basis for that attachment. Healthy attachment occurs when the infant’s needs are met consistently, needs for nurturing, needs for protection, even needs for stimulation, soothing, play, physical contact. Babies seek interaction with many adults in the first few years of life, not any – necessarily a particular adult. However, by about age 7 to 9 months is when we see an attachment to a preferred caregiver. There isn’t a particular limit or number of caregivers. There may be one, two, three or four if you have extended family or consistent daycare providers who are involved. And a child can form a preferred attachment to any of those folks from that age of 7 to 9 months onward.
CAVANAUGH: Okay, so how can this normal process begin to go wrong?
DR. RODE: Good question. Attachment can be disrupted by a number of different circumstances. Most typically what we talk about are children who experience significant neglect in early childhood—by that, we mean a failure to meet those basic needs—or by trauma and abuse. Even extensive separation from a primary caregiver, maybe due to medical issues so if a parent is absent or a child’s engaged in medical care, there can be extended separation. Or due to circumstances where there are multiple inconsistent caregivers. So when we think about children who are raised in institutional settings where there may be nurturing caregivers but so many different ones that there isn’t an opportunity for the child to selectively attach.
CAVANAUGH: Now you said in the normal process of attachment, it even affects a child’s neurological development.
DR. RODE: Umm-hmm.
CAVANAUGH: So do we know what happens to kids whose normal attachment is disrupted in the manners that you’ve said? What – Do we know what is actually going on that’s not happening that should be happening?
DR. RODE: Well, they’re not learning the basic skills for social relatedness. So if an infant cries, it’s an expression of a need and what they’re learning is, when I communicate a need it gets met, so the basic skills in communication whether it’s crying in infancy or language development a little bit later on.
CAVANAUGH: And anything else?
DR. RODE: So another example might be self-soothing. So infants who are distressed are picked up and they’re rocked and they’re soothed, and the brain learns to respond to that soothing. And children in normal development are able then to learn how to do that for themselves but when you don’t have that even in the beginning of the attachment process, it’s much more difficult to learn that skill. And in older life, what that looks like is emotional regulation so the ability to manage your emotions in all different kinds of settings and environments.
CAVANAUGH: I think it’s sort of an instinctive thought of people, Dr. Rode, that when a child has been in an institutional setting, an orphanage, or hasn’t had their own family or hasn’t had a lot of attention, the proper attention growing up, that when someone comes along who’s full of love and full of caring and full of attention, that the child would automatically respond to that and be so grateful for it…
DR. RODE: Hmm…
CAVANAUGH: …and just love it so much. But that doesn’t always happen, does it?
DR. RODE: Right. Because the child may not have the core basic skills to have, say, for example, gratitude. Gratitude is not an innate thing, it’s something that we learn. So, and even how to feel and respond to loving relationships, there’s a learning component to that. So for a child who hasn’t had good attachment early on, they also haven’t had those learning opportunities.
CAVANAUGH: Let me get Brent Yoder into the conversation. He’s, as I said, executive director of Adoption Options, Incorporated. And, Brent, I can only imagine how you responded to those news reports following the case in Tennessee connecting attachment disorder to children adopted from Russian orphanages. In your experience with placing Russian children with American adoptive parents, has – have there been these problems with attachment disorder?
YODER: No, I want to distinguish between attachment disorder and attachment issues…
YODER: …because I think it’s really important to note that there’s a difference between that. Attachment disorder, as we’ve seen kind of rarely, we do see them but they’re more rare. Attachment issues where kids have not learned to be able to respond to affection or, as Dr. Rode indicated, respond to some of the cuing, that’s pretty common but those are things that can be learned by children.
DR. RODE: Umm-hmm.
CAVANAUGH: And tell us the distinction, Dr. Rode, if you would, between these attachment behaviors and an actual attachment disorder.
DR. RODE: Sure, I agree with what Brent said. So children from all different walks of life may have difficulties with attachment in different ways. That doesn’t mean they have a disorder. So when we talk about reactive attachment disorder, we’re talking about a clinical diagnosis based on the DSM, or the Diagnostic and Statistical Manual which is used in psychiatric and medical care. Let me describe the particulars of the diagnosis. So it’s defined by distinctive patterns of disturbed and developmentally inappropriate social relatedness across many contexts and it’s evident before the age of 5. So it’s important to note that this is an early childhood disorder in its development. And it occurs in children who have been maltreated or raised in environments that limit the opportunities for selective attachment. So that piece of the early childhood occurring in that kind of maltreatment environment is critical to the diagnosis itself. And, in fact, it cannot be diagnosed in the absence of that known environment in childhood.
CAVANAUGH: And just one more question before I go to the phones, if I could, Dr. Rode, that was a very scholarly kind of definition.
DR. RODE: Umm-hmm.
CAVANAUGH: What does it look like?
DR. RODE: Sure.
CAVANAUGH: What does it look like if you’re approaching a child who actually is suffering from a manifestation of these behaviors?
DR. RODE: That’s an important question because it can look very different given the different child. So there are two distinct types that are recognized. So one of them is called the inhibited type, so this is the child who is very withdrawn and really seeks no one, does not seek interaction or support from others. So the child fails to initiate social interaction or fails to respond to those social interactions. They’re inhibited, shy, withdrawn. But they may also be what we would call hyper-vigilant. So this is a child who’s sort of constantly on watch for what’s happening around them, easily startled, easily distressed. They may have difficulty with their emotional disregulation, so very easily upset. The other pattern looks very different. So it’s the disinhibited type. This is the child who seeks anyone for contact. So their attachment is what we call diffuse. They seem to be able to attach and detach from any number of individuals and they don’t show a preferred attachment so they would be just as likely to approach mom or dad as they would a complete stranger. They’re attention-seeking, they’re superficial, so on the surface they look like very engaging children but really difficult in those interpersonal relationships.
CAVANAUGH: I’m speaking with Dr. Cheryl Rode, and my other guest is Brent Yoder. We are talking about attachment disorders, attachment disordered behaviors as well, in adopted children. Our number is 1-888-895-5727, 1-888-895-KPBS. We have Tim on the line right now from Point Loma. Good morning, Tim, and welcome to These Days.
TIM (Caller, Point Loma): Thank you, Maureen. Thank you for having this topic. It’s very close to my heart and my wife’s heart. We adopted our son, Kai, through Brent’s agency two and a half years ago and just a couple of brief comments is we were certainly aware of this issue and through Brent’s organization and through help of other websites and doctors, really tried to educate ourselves on the issue as well as I think it’s very important where you adopt a child from that that orphanage where we adopted Kai from was in Russia, that that actual orphanage is well set up, well managed, and the children are well taken care of.
TIM: We’ve all heard horror stories of Romania as well as in Russia, some areas that are not well maintained, well cared for. And through Brent’s organization, we were able to identify a region that had terrific orphanages. But there’s a point – and also, like Brent’s organization and other organizations have terrific post-adoption services, too, which would help on an issue like this.
CAVANAUGH: Right, how…
TIM: But it comes down to…
TIM: There’s also a point where, quite frankly, it comes down to a point where you roll the dice. You can do all your homework, you can see the orphanage, you can interact with them. We actually made three visits to Russia, just the way it was set up. We felt comfortable but there’s still a point where you just go we – we’re taking this child into our lives and we know the issues and we’re just going to roll the dice a little bit. And that’s what’s so sad about the issue in Tennessee…
TIM: …for a number of reasons. Luckily, and we’re very blessed that with our son Kai we’ve not had any issues like this whatsoever. It’s worked wonderfully, thanks to Brent’s organization and just, again, quite frankly, the roll of the dice to a certain point. So those are my comments and thank you so much for having this topic on the air.
CAVANAUGH: Well, Tim, thank you for sharing your story with us. It’s very, very important to hear from someone who’s actually gone through this process. Brent, let me ask you again, apparently Adoption Options, your organization, according to Tim and yourself, go through this step by step to make sure that the adoptive parents know what they need to know to make sure that the places, the orphanages in Russia, are up to a certain standard. What, though, have you heard about problems with attachment behavior in some of the children who have been adopted through your agency?
YODER: Well, again, I think that if we talk about attachment issues that the older the child, the more likely they’re going to come with attachment issues.
YODER: But I distinguish that between disorder…
YODER: …because, again, you know, attachment issues are ones that can be worked through, can be resolved, and eventually the kids can make adjustment. Kids are very adaptable if they receive the basic needs. So they’re, you know, very adaptable to their new environment. It may take them some time but they do – most of them do adjust.
CAVANAUGH: Now Adoption Options, do you help a parent – perspective adoptive parents here in San Diego?
CAVANAUGH: I wonder, you know, one of the things that I was curious about when I was preparing for this interview is why is it that Russia has children up for adoption?
YODER: The primary reason is poverty. You know, Russia is very impoverished in many areas of Russia and so that’s the primary reason children are available for adoption.
CAVANAUGH: And what is the procedure? I would imagine that this – I know that there are diplomats working now to iron out problems between the United States and Russia caused, at least brought to light, by this Tennessee incident. How long does it take for someone to actually want to adopt and before they would actually be able to come home with a child from a Russian orphanage?
YODER: Well, the minimum of time would probably be somewhere around six months. Most people take close to a year. It requires that they have to be screened at home by – and to have had a home study done with them for approval from the State of California and then they have to be able to select a child. In the process of selecting a child, they’re presented with the medical and the history of the child, at least what’s available. They then make their first trip to Russia to be able to visit the child. At that time, they see the entire medical, and then spend time with the child and can ask for, you know, other kinds of help in assessment of the child. Then they select – if they’ve chosen the child, then they return in about six to eight weeks for their adoption trip, again visiting the child and completing their adoption, and then they still will need to wait for another probably two to three weeks before they can bring the child home. So many people will make actually a third trip before they bring the child home.
CAVANAUGH: Right. You know, in this Tennessee case, I know that we don’t know the specifics involved but the Russian authorities were adamant that there was absolutely nothing wrong with this little boy. How have you found Russian authorities to be in how they present the children for adoption? Do you work with people that you trust over there?
YODER: Yes. The Russians, by and large, tend to be overly harsh on their assessment of children rather than the opposite. So they tend to be very harsh with their assessments of the children. That doesn’t mean that all children come with everything being identified because there are gaps. There’s gaps between the Russian medicine – the medical way they would evaluate children versus the American way they’d evaluate children. That’s why we insist that families use an American doctor to help them in their assessment…
CAVANAUGH: I see.
YODER: …of the children but it still doesn’t eliminate all risk. There’s still chances that some things could come about and with older children, I think the risks are higher because, quite frankly, you know, the – it’s a formidable task for them to try to adjust to a new country, a new language, a new family. I mean, it’s a tremendous adjustment issue. I – My one comment about the lady who returned her child is just the very act and the way she returned her child would signify to me somebody that was very angry. You know, to send a six, seven year old child by himself back on the plane and not ask for assistance while you have them at home says – makes a statement about her rather than the child.
DR. RODE: And I would concur. I think probably the most important thing that we can learn from this story is how important it is to reach out for help and support when you’re parenting a child with special needs, whatever those needs may be, international adoption, domestic adoption, foster care, or your own child. There are many, many support services available and in San Diego County, we’re blessed with the amount of services that we have and that parents can and should be a very positive advocate for the wellbeing of their child. And as Brent said, they should know the risks in bringing in an adoptive child and be prepared to work with those risks to eliminate the impact that they have on that child’s functioning.
CAVANAUGH: We have to take a short break. When we return, we’ll continue our discussion about what prospective adoptive parents should know about potentially difficult adoptions. Our number is 1-888-895-5727. We’ll return with your calls and our guests here on These Days on KPBS.
CAVANAUGH: I'm Maureen Cavanaugh. You're listening to These Days on KPBS. My guests are Dr. Cheryl Rode, Director of Clinical Operations for the San Diego Center for Children. Brent Yoder is Executive Director of Adoption Options, Incorporated. We’re talking about the fallout from that story last month about a 7-year-old Russian boy who was sent back home by his adoptive parents because they basically couldn’t handle him. We’re talking about, oh, attachment disorders, attachment behaviors, and we’re also talking about how those – how children can be treated if they exhibit some of those problems. We’re taking your calls at 1-888-895-5727, that’s 1-888-895-KPBS. Michael is on the line. He’s calling from University Heights. And good morning, Michael. Welcome to These Days.
MICHAEL (Caller, University Heights): Good morning, Maureen. I’m Michael Jones and I’m a trainer and a psychotherapist working in the area of attachment. I train foster and adoptive parents and child welfare staff and clinicians in this area of adoption. And in private practice, I see kids from the child welfare arena of adoptions as well as from Russia and Kazakhstan, Costa Rica, Ukraine and so forth. And a couple of points about foreign adoptions where I’ve worked as well, is people often go to other countries to adopt for a couple of very personal reasons. One, they want to pretend that the child was born to them and they do not want contact with biological parents, and they pay thousands of dollars to do that and often ignore the information given, if it’s given, about compromised attachment in these kids. If the kids are in Russia, Kazakhstan, other countries, China, where the kids are in orphanages, we don’t know whether they were born in orphanages or dropped off at orphanages, but an orphanage is not a mom and a dad capable of contributing toward attachment. So all of these kids are coming with compromised attachment, perhaps not reactive attachment disorder, and then they have the added trauma of being removed from their country, their language, their culture, to this one. And so those are the kids I see five and ten years after the fact in my office with severe attachment problems and very angry parents. You mentioned the mom sending her child back to Russia, very angry. Well, what – that’s one of the symptoms of compromised attachment, an angry parent. And so, you know, there are children right down the street in the child welfare system who are available for adoption that we know much more about. They, too, come with trauma and compromised attachment. But we have all of these kids from around the world in the United States and when there are angry parents five and ten years later who have not sought support of support groups and therapeutic interventions to ameliorate the attachment issues, these kids wind up in our group homes…
CAVANAUGH: Right, right.
MICHAEL: …in our facilities, and we’re paying those bills through MediCal because their parents may not have sent them back to Russia.
CAVANAUGH: Michael, thank you. Thank you very much for the call. I want to ask you, Brent, what do you hear from parents who contact you. Why do they want a foreign adoption?
YODER: I think that, you know, what he said, it’s partly they do not want to have an open adoption so that’s one of the reasons. But most times they come because of child availability. Contrary to what, I think, this last person said is that the availability of adoptions, the difficulty of doing a domestic adoption in the United States is not easy. It’s formidable to most families. So international adoptions opens up the available – much more availability of children.
CAVANAUGH: Dr. Rode, would you agree? Is it too difficult to adopt a child here?
DR. RODE: Absolutely not. And, in fact, at San Diego Center for Children, we have a Special Families Foster Care program that helps families and potentially adoptive children come together in very, very successful ways.
CAVANAUGH: Well, let me ask you, Brent, I know that there is a syndrome – well, I’m using that word completely colloquially. There is something called orphanage behavior. What is that? And what do parents deal with when they get a child from an orphanage who is exhibiting orphanage behavior?
YODER: I think that what they – it’s probably unique to the individual problems they may have. But, you know, a lot of times it’s about patients to be able to stay with the child for the child to learn new behaviors to replace it. As an example of orphanage behavior may be like head-banging maybe as a primitive way of comforting a child does. To replace that just takes some patience to be able to do that, sometimes some outside support to help with that but most times with patience that they tend to disappear.
CAVANAUGH: And what does – I know that, you know, your agency has protocols and so forth.
CAVANAUGH: What is it that you do to help parents who perhaps are having a little bit of difficulty in introducing this new child into their home environment?
YODER: Well, our first step is to be able to connect them with other families. You know, the families are tremendously supportive of each other and tremendous outreach to each other to help each other in sharing their experiences and ideas about how to help each other, even to give respite care at times with each other. So an example of that is then with this most recent incidence of the child being returned like over 25,000 people signed within a week, signed a petition to continue adoptions supportive of that – of the families continuing adoptions. But, you know, if they – and so we first try and network with other families then we will start to connect them with resources in the community to help them out as well.
CAVANAUGH: Dr. Rode, what do you do when you see a child exhibiting these behaviors, a number of these behaviors that they actually have attachment disorder, how can you help – what kind of treatments are available for both the child and the child’s family?
DR. RODE: Sure, that’s a great question. Let me speak to that with regard to our foster care treatment program. So San Diego Center for Children definitely helps many children who have experienced neglect or trauma or who may have been institutionalized at an early age and have a range of mental health issues. Some of the children that we help through our foster care and adoptive programs certainly do have attachment issues so treatment really is a combined effort with working with the child to help them develop the necessary skills for social relatedness and also working with the parents, whether that is foster parents or biological parents with whom a child may return to learn appropriate parenting skills. Use the word patience, patience is a core skill in working with these children but there are many, many skills that the parents need to have in order to help the children learn these skills that they might have missed at an earlier stage of development.
CAVANAUGH: Now as a non-mental health professional, I would interpret the idea of connecting with a child like this as having the child learn to develop trust and love but if the issues are deeper than that, if those connections are not really there inside the child, how do you actually create that if it hasn’t formed when it should have formed…
DR. RODE: Umm-hmm.
CAVANAUGH: …way back when?
DR. RODE: Well, we have to break it down into very specific skills that we want a child to learn. So we use a term pro-social behavior which can mean any number of different kinds of social behaviors that we want to help a child learn, as basic as asking when you need help, having the language to do that, knowing when the opportunity is there to do that and simply practicing trusting the adult or going to the adult in order to request that help. So we want to break these ideas down. Love and conscience and those things are very, very sort of vague terms, so we’re looking at very specific behavior patterns that we can teach a child and then encourage them to use. So skill development is a very, very important piece of that and some of it is done on an individual basis like we’ll have a skills partner who works one-on-one with the child as well as teaching the parent how to encourage those specific behaviors and to reward them when they happen.
CAVANAUGH: You know, Brent, another piece of this puzzle might be in the nature of the people who are seeking these adoptions themselves. I think that I saw that many couples have been through long fertility treatments and they’ve also been trying to adopt in this country unsuccessfully and then they may go on to a foreign adoption. Are – Do you find that some parents who are considering foreign adoptions are particularly vulnerable, particularly maybe raw emotionally from being on this quest for such a long time?
YODER: Oh, yes, I certainly do. I think that our parents are usually very reactive when they first get back and the first thing they think about whenever they run into problems is that this is an attachment issue. Either it’s an attachment issue or it’s fetal alcohol syndrome. They immediately jump to those conclusions without being able to assess it and that’s what, you know, the general consensus is, that, you know, people – anybody who’s adopted, they’ll tell you that people have told them in the community, oh, you’re going to get a child that’s going to be – can’t attach to you or it’s going to end up being a murderer or whatever, you know, so these – many of these people are very frightened and they tend to overreact when they first start to encounter some problems. And so we have to help them to be able to kind of be patient, kind of calm down, be able to do a more accurate assessment to see, really, what they’re dealing with.
CAVANAUGH: I think we can squeeze in one more call. Victor is calling from Valley Center. Good morning, Victor, and welcome to These Days.
VICTOR (Caller, Valley Center): Good morning. Thanks for having me on. I wanted to just encourage your listeners to adopt locally. We have so many kids in need. I did – We, my wife and I adopted two children, one of them, the middle one, actually exhibited some rad type behavior and I don’t want to diagnose him but that’s what he was doing, is pulling away from us. He didn’t want to be hugged, he didn’t want to be held. And we just worked and loved through it, and he is the greatest, most lovingest kid now. I really encourage folks to do that, and you just got to wonder whether when a couple can’t get a local child and they go out of the country, is that encouraging more people to abandon their kids in foreign orphanages.
VICTOR: And is that encouraging people that probably shouldn’t be getting adoption – getting children from out of the country. And it…
CAVANAUGH: Victor, thank you. Thank you for your call. I appreciate it. We’re coming up to the clock here. I do want to ask you, Dr. Rode, because one of the points that Victor makes is that this is not just a subject of foreign adoptions. I mean, this is – this can happen not only in a domestic adoption but within a family.
DR. RODE: Umm-hmm.
CAVANAUGH: Is that correct?
DR. RODE: Well, remember when we’re talking about attachment disorder…
DR. RODE: …we are – when we use the term disorder, it specifically requires that there have been circumstances of abuse or neglect within an environment, an early childhood environment. And as Brent said early on, the diagnosis itself is extremely rare and it’s likely to be found in kids who have experienced significant degrees of trauma and neglect. In typical families with adequate nurturing, you will not see these kinds of diagnoses. You may see other behaviors that look similar but are reflective of either other diagnoses or other developmental patterns in children.
CAVANAUGH: Brent, I want to ask you quickly, one of our callers said he went through the process with your agency and it turned out great for him but he also called it a roll of the dice. Would you agree with that?
YODER: I probably wouldn’t be as – say that it’s a matter of luck because most of the families, you know, do quite a bit of assessment of the child, and I think that most of them would say that they have adopted a child that are (sic) relatively healthy.
CAVANAUGH: Well, I want to thank you both for so much good information. Brent Yoder, Executive Director of Adoption Options, thank you so much.
YODER: Thank you.
CAVANAUGH: Dr. Cheryl Rode, Director of Clinical Operations for the San Diego Center for Children, thank you.
DR. RODE: Thank you, Maureen.
CAVANAUGH: And if you’d like to comment online, please do, KPBS.org/thesedays. You’ve been listening to These Days on KPBS.
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