Parents often ask Lucy Daniels Center clinicians for guidance with children who they have adopted from a foreign land. Our experience has been that parents are generally concerned about children who have been adopted toward the end of their first year of life or later. These concerned parents wonder if there is a problem in the attachment that they and their child have formed. Attachment refers to the loving and dependent relationship that an infant develops with one, or sometimes two, caregivers. This attachment is generally established during the first year of life and requires the intense, responsive, dependable presence of the caregiver(s). On the basis of such positive attachment, children learn to trust and depend upon people to meet their needs. Eventually, children must develop beyond the attachment relationship of infancy to independence and autonomy through the process of separation. The separation process expectably begins toward the end of the child's first year and is a central task during the second and third year. Separation also requires the caretaker's presence and support for each gradual step toward independence. The sense of autonomy that enables a child to mange his own needs, emotions, impulses, and values, depends on a successful separation experience.

Attachment sequences are biologically determined: In a manner similar to many other aspects of development, children seem to attach and separate using biologically pre-determined behaviors that appear at predictable times and sequences. For example, children show the attachment behavior around three months known as the "social smile" and the separation behavior around nine months known as "stranger anxiety." Children seem to be designed to have a deep attachment to a caregiver by age six months or so. For this reason, it appears that adoptions before age six months generally do not lead to attachment problems. The child is still open and searching for someone to respond. After six months of age, a child may begin to slowly close down the window of opportunity and even start to build up internal walls against relationships. Interferences with attachment and separation put children at risk. They may find it difficult to comfortably trust another person or feel comfortably autonomous.

Although for reasons that remain a mystery many children have the capacity to catch up successfully with "missed" developmental achievements when offered a loving and supportive environment, many other children cannot catch up in normal way. Sometimes the interference with this critical stage of development is extensive enough that a child is described as having a Reactive Attachment Disorder of Infancy or Early Childhood (RAD).

Patterns of attachment disorder: There are two common types of attachment disorder that are distinguishable by specific patterns of social relations. Children with the "inhibited" type of RAD tend not to initiate or respond to social interactions. These children can be mistakenly thought to be shy. Children with the "disinhibited" type of RAD tend to have an indiscriminate sociability, or a lack of selectivity, in their choice of attachment figures. These children appear to be charming and find their way into every adult's lap. Although these friendly children can appear to be comfortable with people, they have a shallow attachment without the needed deep preferences. Evaluation by a qualified professional can determine if the basis of the problem is RAD or another condition within which these patterns of social relations can also appear.

Because attachment and separation are such fundamental building blocks of emotional development, children with attachment disorders often have a variety of symptoms. They may be clingy and demanding, controlling, have reduced frustration tolerance, or be overactive and distractible. These children may also chatter incessantly, be superficially "charming," demonstrate a lack of understanding of cause and effect, lie, be aggressive and destructive, inflict physical attacks upon self or beloved possessions, show a lack of remorse, exhibit anxiety (including excessive concerns about injuries), and have poor judgment about danger. Because RAD often occurs in the context of prenatal nutritional deficiencies or substance exposure, or post-natal deficiencies of nutritional or physical care, children with RAD have a greater than expectable chance of also having speech, language, or other physical developmental delays.

Treatment: The most important thing for parents who are concerned that their child may have attachment problems is to know is that their child can be helped, and that parents can also be helped to understand their child's special needs. Because the label of Reactive Attachment Disorder does not begin to fully describe any child as a person, with his or her particular history, family, talents, assets and challenges, it is difficult to be specific about the most appropriate kinds of help for any child with attachment problems. In general, parents will have to help their child with any problematic behaviors as they simultaneously focus upon his or her basic problem with attachment. Parents will need to find a delicate balance between expecting age-appropriate behaviors, and allowing certain attachment behaviors that would be appropriate for a much younger child. Also, we recommend that children with problematic early attachments will need to focus their emotional life as fully as possible upon their parents. This will require much parental time and sacrifice because these children not only has the usual needs of young children, but need extra time, empathy, and assistance to make up for what they did not get earlier and to help face and overcome the emotional consequences of early experiences and deprivations. As an illustration of this sacrifice, we generally recommend that parents refrain from placing a child, adopted after the age of six months, in childcare. Bringing a child to a new family, to a new culture, to a new language, and after a matter or weeks or months, asking that child to not only relate and "attach" to new parent(s), but also to spend large portions of the day with a number of other adults and children in yet another place complicates the preventative and remediative task that parents face with such children.

Parents have extra work with the children we have discussed. It is difficult and painful for parents as they empathize with the inner pain of their child, but we urge parents to retain confidence in their ability to reach the heart of their child and to retain hope in the enormous potential of their child to respond to those who reach out lovingly.

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