by Walter D. Buenning, PhD
Originally printed in Chosen Child Magazine, reprinted with permission
Increasingly, more and more is being written about bonding and attachment. What is attachment? Bonding or attachment refers to the emotional connection or the strength of the relationship between one person and another. Usually it is between a child and his parents. In this article I will refer to attachment as the capacity of an infant or child to form a close, trusting and loving relationship with his mother and father. In professional circles, when a child or baby has a problem attaching or bonding to his parents, it is called a Reactive Attachment Disorder (RAD). As the name implies, difficulty with bonding is a reaction to something that child has experienced.
If a baby is traumatized early in life, it usually affects his ability to bond. The extent of the baby's difficulty depends on the severity of the trauma.
One group of children who are traumatized are those who become available for adoption. Every baby who becomes available for adoption has experienced some trauma. The most common trauma they can experience is the loss of their relationship to their birth mother. Over the past ten to twenty years, there has been growing evidence that a strong or significant bond exists at birth between the infant and his birth mother. This bond develops during the nine-month period the child was inside his mother. When the baby is born, he already has a bond with his birth mother. In my experience, besides food and air, nothing is more important to a baby's survival than his mother's love. When the love from his relationship is lost, regardless of the reason, the bond is broken and the baby is adversely affected.
Many babies who are adopted at birth or shortly thereafter, bond to the adoptive parent or mother without any problems. Others do not. We do not clearly know the reasons why. We also don't know how frequently this occurs. Based on my clinical experience, my estimation is that it occurs in 10-30% of infants adopted at birth. If other harmful experiences, such as neglect, abandonment, abuse, or multiple placements are added to the loss of his birth mother, the resulting damaging affects are compounded. The more severe the problems in the relationship with the birth parents, the more difficult it will be for the child to receive and give love to the new adoptive parents.
For years, little was known about bonding. RAD as an emotional disorder was not even identified. Even now, many clinicians and most parents have not heard of RAD. In the past and sometimes today, when adoption agencies placed babies or children, bonding or attachment and the possible problems that could arise in this area were not taken seriously enough. Too often, parents and agencies believed that if a baby or child were placed with loving parents, all would go well. We all know that babies need and want love. Adoptive parents are motivated to nurture and love their adoptive babies. Consequently, it should be a perfect match. Unfortunately, anyone who works with adoptive families knows that too often something goes wrong.
What I have seen is that bonding is a two step process. First, the parents must give the child love. Secondly, the child must accept it. The problem arises in the second step or phase. Because of past loss, some children are unable to trust. They are unable to accept the new parent's love and risk losing it as they did with their first parent. It is difficult for most parents and may clinicians to believe that this could even happen with children and even infants. In adoptive homes, love is like a gift given to the child. The core problem is that the child does not accept the love. In the end, the result is that the child looks and acts like he has not been loved.
For some parents and clinicians, it is understandable that a three or four year old child may not accept an adoptive parent's love. But for many parents and many clinicians, it seems illogical that an infant would resist being loved. There is no doubt in my mind, however, that a percentage of infants adopted at birth actively and spontaneously resist accepting their adoptive parent's love. Everything in normal experience would tell us that babies want to be loved and if you give it, they will accept it. If something has gone wrong with the original parent-child relationship, however, the baby can be too afraid to again risk loving and being abandoned. When this happens, the parents will often try to give even more love. Usually this does not work. Over time, the parents become more and more frustrated and feel rejected by the infant who resists virtually all their efforts to love him. Over time, may mothers and fathers who began with a heart full of love and hope, end up defeated, discouraged, and angry. Often they have a tough time, after years of such rejection, liking their child much less loving them. If they go for help, the child with RAD usually presents to the clinician as a friendly, cooperative, and healthy child. On the other had, the parents, particularly the mother, often appear frustrated, angry and critical toward their child. The clinician frequently concludes that any problem that exists must result from the mother's anger and criticism toward her child. Consequently, mothers become the focus of therapy and as a result feel even further misunderstood.
The first task in solving the problem in a child with RAD is detection. It is essential for parents who have an unbonded baby or child to discover it early and seek help. As with most, if not all medical conditions, early detection and intervention is always best. The sooner you can determine if there is a bonding problem with a baby or child, the more quickly we can intervene and provide help. For several years I have thought that all babies who are adopted should have routine attachment checkups, just as there are well baby medical check-ups. After the child has been placed with a family for several months, bonding should have begun. Evaluations could be done on four to six months after the placement, and on a regular basis, thereafter, every four to six months. The evaluations could stop after two or three "problem-free" check-ups.
While parents should not be making a final diagnosis, they are the most likely persons to know if a problem exists. Often the child with RAD hides his problems from the outside world. Consequently, adults such as teachers and relatives often see the child as normal or as a "great kid." Meanwhile, the child is very symptomatic at home, especially with his mother. In some extreme cases, the child even hides his symptoms from the father, displaying them only to his mother when the two of them are alone. In these families, even the father doubts the mother's report of how disturbed the child is.
In order for early detection to occur, it is essential that parents know the core symptoms. This will give the parent warning signs that their child is having trouble bonding to them and may have developed RAD. There is a growing body of knowledge about RAD in children who are three or four years old or older. However, RAD often develops in infants. If it is detected in infancy, it can be healed very quickly and effectively. Even with children who are five or six years old, treatment may be very successful in a brief time. With older children, the task is harder, but doable.
Parents are in the best position to see the true nature of their child. If they are educated about RAD, they can help detect the condition early. With this information, parents can seek help from a professional who can confirm the diagnosis and provide treatment.
Reactive Attachment Disorder (RAD) is a relative condition ranging in severity from mild to severe. The level of severity is directly related to the extent and duration of the child's early trauma. Abandonment is usually part of the history of RAD. If neglect and abuse are added to the child's early history, the resulting condition is generally worse. Usually, the earlier the trauma begins and the longer it lasts, the more severe the RAD condition will be. Diagnosis is best made by assessing the current symptoms of the child and is confirmed by the child's history. Information taken from the parents is usually more valid than a clinician's perception of the child. This is true because the child with RAD has the capacity to manipulate and fake "looking good."
When more symptoms are present, your child has a greater chance of having RAD. Similarly, when more items are listed as severe versus mild, the condition is more serious.
Children with milder forms of RAD usually can express genuine love for their parents. Parents of children with severe RAD will often describe their child as lacking genuine loving feelings for them.
RAD children may have difficulty accepting or seeking out physical affection and touch. If you touch a child with RAD, often she will recoil or flinch and say, "Ouch," even though your touch is gentle and should produce no pain. "What would life be like if all touch either tickled or hurt?" I believe this is how many unattached children experience physical closeness or touch. [This discomfort with touch may also be a symptom of Sensory Integration Dysfunction, which is extremely common in Post-Institutionalized children.]
All children with RAD have control issues. The key question is, "How extreme or intense is their need to be in control?" The child with RAD is oppositional, argumentative, disobedient or often defiant. They are exceedingly strong-willed and will go to great extremes to be in charge. Their need to control comes from their intense fear that further harm will occur if they're once again as helpless as they were as babies.
Most children with RAD have problems with anger. Many will express their anger overtly, having frequent temper tantrums and a short frustration tolerance. A smaller percentage of the children will be passive-aggressive and engage in annoying, frustrating, and aggravating behavior. Often this is disguised by a facade of innocence or hidden in socially acceptable behavior. For example, a child with RAD can hug a parent so hard it physically hurts. To a casual observer, it would seem the child's hug was a loving act. In reality, the child inflicted pain, a hurtful act, within a hug, which is a loving act. This is the hallmark of passive-aggressive behavior or indirect anger.
Children with RAD have problems developing a conscience. In the most severe children, their conscience is entirely absent. They have no remorse, regret, or guilt when they violate their parents' or other people's rights. In the milder condition of RAD, the conscience is underdeveloped. A number of the items on the checklist are related to the child having little or no conscience.
All unattached [or anxiously/avoidantly attached] children have trust issues. They do not trust their parents and the parents cannot trust their children. The severity of trust issues is directly related to the severity of the RAD condition. A number of the checklist symptoms assess the child's desire and willingness to live outside their parents' circle of control by being deceptive and disobedient.
A diagnosis of RAD can be made in an infant with only several items checked in a positive direction. RAD is detectable early in infancy. Originally, my work with RAD was with older children, not infants. As I worked with the parents of these older children, many reported thinking something was wrong with their child as an infant. . .
There are two major groups of unattached babies. The first group consists of babies who are fussy and unhappy. They are visible disconnected and cry extensively. They are often inconsolable and reject nurturance and comforting from their parents.
The second group consists of babies who are overly good. They are calm, quiet, and appear independent. Usually they have a flat affect and calm appearance. They make few demands upon their parents. For example, if the parents place them on the floor, they can happily entertain themselves for an hour or more. They rarely cry or are fussy.
There is another scenario that is prevalent with RAD. Babies can appear bonded in infancy only to develop symptoms of RAD as they become toddlers. Over the years, many parents stated their babies appeared bonded during infancy. Either RAD was not present in infancy and developed later, or the parents did not recognize the RAD symptoms in their baby. As their baby grew older, he either developed RAD or the condition then manifested itself in ways the parents could easily recognize.
As parents, you are in a position to see the early signs of problems in your baby. Even if the condition is mild, RAD is serious and should not be ignored. A mild attachment problem in infancy that is manageable or undetected can lead to significant emotional and behavioral problems in toddlers and older children.
Therapy for RAD Children
When therapy is conducted, several modalities can be used: individual, parent, family and group therapies. In my experience, doing individual or group therapy with the RAD child is largely ineffective. This is because most RAD children lie, minimize, and deny their problems. Without the parent's input, the RAD child can effectively fool or manipulate almost all clinicians. . . Parents have not reported success when their children were in individual or group therapy. I use family therapy exclusively. The parents are always present when I work with their child. This gives me access to the truth. Without real facts, help is impossible.
Family therapy is the most effective modality for other reasons. Parents are the most powerful, responsible and influential people in their child's life. They are the therapist's greatest ally in helping a RAD child. Consequently, teaching and educating parents how to bond with their children becomes a major part of family-based attachment therapy.
The therapy needs to be confrontive. The RAD child cannot be given the choice of facing or talking about his problems. If the decision is left up to the child, he will generally meet for months or years and not discuss his present problems or past trauma. When the parents are present, he can be more accurately confronted with his issues. This makes the therapy unpleasant and difficult for the child. Until he has made significant progress in bonding to his parents, the child will usually detest the therapy. One rule of thumb for me has been, "If your child likes his therapy, it probably is not being helpful." In all likelihood, therapy is fun because your child is allowed to avoid his problems and be in control of the process.
The most helpful attachment therapy also provides extensive help to the parents. Nothing in normal growing up years or adulthood prepares us to parent RAD children well. Parents of RAD children need information and training on how to therapeutically parent their children. The therapy should give parents ideas and skills that accomplish the following goals:
When Foster W. Cline, MD began working with RAD in the early 1970's, little was known about RAD. Even less was known about how to help these very troubled children. It was apparent that they did not respond to conventional therapy. An innovative therapy called Holding Therapy (also labeled Rage Reduction Therapy) showed promise. Over the years, the therapy has been used by an increasing number of professionals. As more clinicians have used holding with RAD children, the therapy has been refined and redefined. As a result, a diversity of interventions exists among professionals using this modality. They all have the same label, namely Holding Therapy. While there are common threads, a wide variety of therapeutic activities now take place within the definition of Attachment or Holding Therapy.
Some attachment therapists do not believe in using the holding modality, but many do. Some do not believe the parents should hold their child, delegating that task only to therapists. Others teach parents to do most, if not all, the holding. Some use only nurturing holding while others also use holding for control (restraining or containing holding). Without talking to each specific therapist, a parent should not presume to know what a therapy involves just by knowing that the therapist does Attachment or Holding Therapy.
RAD children are almost always intensely angry children. If therapy is effective, it will constructively address the child's anger. One therapeutic goal is to reduce the child's anger. When it works, this is a sign of success. Hence, the label Rage Reduction Therapy was fitting. Present attachment therapies, however, address a broader range of emotions, including intense fear and sadness. All attachment therapy of which I am aware has an emphasis on addressing the child's troubling emotions versus being only a cognitive or behavioral approach.
The goal of therapy for a RAD child is not to reduce his anger or to change his behaviors. The ultimate goal is to attach or bond the child to his parents. The goal is not to develop a good relationship between the child and therapist, but between the child and his parents. As such the therapy is most accurately called Attachment Therapy. When your child becomes bonded, changes will take place spontaneously. Changes in emotions, behaviors, attitudes and thinking will happen automatically.
RAD is a condition with a wide range of severity. Do not approach it lightly hoping you can heal it yourself by reading several articles or books. While educating yourself is helpful, it is rarely by itself the solution. Seek help, for both diagnosis and treatment, as both are becoming more available. Many families settle for months or years of therapy with no appreciable improvement. Continue to search for a clinician who can help you and your child.
Dr. Buenning would be glad to consult with parents having concerns regarding their children:
Parent Coaching and Attachment Therapy via Skype or phone
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from Lilo & Stitch (2002, Movie)