More About Adoption and Reactive Attachment Disorder: Mind That Diagnosis

At http://www.facebook.com/ReactiveAttachmentDisorderCommunity, some people are incensed by the fact that “someone” has said that the diagnosis of Reactive Attachment Disorder does not include symptoms like violent behavior. They say that anyone who says that ought to see what their kids can do.

But, as Lyndon Johnson and the Bible used to say, “Come, let us reason together.” No doubt their children are violent, as reported. If they aren’t, well, some children assuredly are. No one has said that children aren’t ever violent, just that violence is not one of the symptoms of Reactive Attachment Disorder.

So, we have kids whose violence has been reported, and those are also kids who have been said (by somebody) to have Reactive Attachment Disorder. Suppose one of those things is not true? Which is it more likely to be--  that they aren’t really violent? No, it would be a bit too conspiracy-theory to imagine that a group of parents have invented this report. What about the alternative—that they don’t actually have Reactive Attachment Disorder, or, if they have it, they have some other serious problems as well? Those problems could be other diagnostic categories that haven’t been stated or mentioned, or of course the problems could result from various difficulties of one or more other people in the household, as family therapists have told us over and over.

Not knowing the families, I am not about to say whether violence may reflect family problems. Knowing how the Internet has presented Reactive Attachment Disorder, however, I am prepared to say that a diagnosis that is based on one of the many “checklists” (like the one at www.attach.org) is not going to be an accurate statement about the presence or absence of that specific disorder.  And I’d like to put in a request: before people fulminate about whether their beliefs about violence and RAD have been attacked, they should get a complete assessment done by a licensed clinical psychologist, with a doctoral degree in clinical psychology from an accredited university, and by a physician with some training in behavioral issues. Do those practitioners diagnose Reactive Attachment Disorder, or was the diagnosis done by the parent using a checklist, or by a “registered attachment therapist” with no training in any other aspect of childhood emotional disturbance? If the latter, I would suggest, folks, that you re-think what you’re dealing with.  An assessment, by the way, doesn’t stop with a diagnosis, but describes specific problems that need help.

To go on with this issue, let me point out that only your health insurer really cares what name you give a disorder. Treatment focuses on what symptoms are shown, and within some limits that treatment will be the same no matter what DSM code is written on the bill.

A lot of people have gotten the idea that if a child has had a poor care history—is post-institutional, for example--  that’s all the evidence needed for a diagnosis of Reactive Attachment Disorder. As I’ve pointed out in other posts, the work of Michael Rutter and the English-Romanian Adoptees study group has shown that most children adopted from really awful orphanages do very well. The biggest general problem in the early years is delayed language development.  An American group has shown that improving orphanage conditions improves child outcomes (even though they’re all still separated from their birth mothers, etc. etc.).

Writing in Infant Mental Health Journal (2011, Vol. 32[2]), Christina Groark, Robin McCall, and Larry Fish, in “Characteristics of Environments, Caregivers, and Children in Three Central American Orphanages” have described both children and experiences in those institutions.  The authors point out that children may have very different experiences in orphanages, and that they may have had harmful experiences even before entering the institution.

The characteristics of the orphanages give some possible insight into children’s developmental difficulties and show us how much more there is to think about than a simple diagnostic category. Most of the wards had 8 to 12 children aged birth to 7 years (grouped by age), but in one orphanage there was also one single room with about 50 infants and young children, with each caregiver informally taking charge of a certain part of the room. Child to caregiver ratios were from 8:1 to 12:1. Caregivers worked long shifts—even 24 hours—and then had 1-3 days off. Children thus had little opportunity to spend much time with any one caregiver, and there was little time for a caregiver to get to understand each child well. Children also “graduated” to a new ward periodically. As Groark and her colleagues put it, “while caregivers were stably employed, they were not consistently present in the lives of children, who tended to see new caregivers from a set of 6 to 9+ every day or every other day, experience different substitute caregivers as needed, and graduate to new wards.”

The children (mostly under 7 years of age) were described as having “exceedingly low” behavioral development. They also showed quite high rates of indiscriminate friendliness to a stranger and were frequently noncompliant and provocative, and even interpersonally violent, but unlike some other post-institutionalized children who have been described, they did not show much impulsiveness, impatience, or frustration, or stereotyped or withdrawn behavior.

It’s notable that this article did not use the term Reactive Attachment Disorder or any other diagnosis of the children’s characteristics, and it’s hard to see what good would come of anything other than describing what the children were like. Groark’s work was not a study of therapy, but it’s easy to see how helpful it would be for parents or therapists to have specific information about child behavior rather than a diagnosis which gives a general--  possibly incorrect--  description, which may apply much better to some children than to others. A diagnosis describes the disorder, not the child, and when we come down to it, we treat, or adopt, children, not disorders.