Frequently Asked Questions

1. We are considering adopting a child from China. As part of the adoption process, we took a course that discussed RAD; however, I am finding the foreign adoption newsletters we subscribe to rarely discuss this problem. Does this mean Chinese children have a lower incidence of RAD than children from other countries?

No. Adoptions from China have been happening for less than a decade, so problems are just now becoming evident. In the first few years of Chinese adoptions, parents were mostly being referred infants, 4-6 months of age so the risk of exposure was lower. Plus, there has been a certain reluctance in some China adoption circles to discuss even the possibility of RAD.

This has created a vicious circle. Because prospective parents are not usually informed about RAD by their agencies, people don't know what to look for. One woman on the attach-china list joined because she thought her second daughter would be at risk because of her placement in multiple foster homes, and then realized that her first daughter had attachment problems

For more information, read Why Internationally Adopted Children Are at Risk for RAD

2. Are there any statistics available on the frequency and severity of RAD in children adopted at less than two years old from China or other countries, or domestically?

There are not any statistics that specific at this time. In his article for Chosen Child Magazine, Walt Buenning states, "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." Children adopted from China have suffered from the additional traumas of abandonment and neglect, so the incidence of RAD would likely be higher.

In his book, Facilitating Developmental Attachment, Daniel Hughes writes "Chicchetti (1989) indicates that many studies document that maltreated infants and toddlers are likely to form... insecure attachment relationships. Estimates of the number of such children who develop varying degrees of insecure attachment patterns range from 70 percent to 100 percent."

"...Patricia Crittenden (1988) found that among children who experienced abuse, neglect, or both, only 5 percent to 13 percent manifested a secure attachment. Of the children who had experienced marginal maltreatment, 36 percent manifested a secure attachment. ... Differences in anxious attachments were also noted between those children who primarily experienced abuse and those who experienced neglect or marginal maltreatment. Among the abused groups, over 50 percent manifested very disorganized attachment behavior with features of both avoidance and ambivalence. In contrast, children who experienced only neglect were much more likely to manifest the anxious-avoidant pattern of attachment."

It is safe to assume, therefore, that any child who has spent time in an orphanage will have attachment problems to some degree. In addition, if there was any in utero exposure to alcohol or drugs, such as is common with adoptions from Russia or the foster care system, attachment will be further compromised.

For more information, read Why Internationally Adopted Children Are at Risk for RAD

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3. How serious are the cases of attachment disorder that the attach-china list has experienced/seen in adopted children from China, Russia, Korea or other countries?

Our families have experienced the full continuum - from mild to severe. Some cases were quite serious and apparent at the time of adoption. Some of these children exhibited autistic-type withdrawal and behavior. Some had the acting out type. Many cases had only one or two signs at adoption, but got worse over time. Some cases are still mild, but parents are seeking help to ensure their children heal before anything more severe develops.

The early signs are undoubtedly more serious than many parents want to acknowledge. Parents almost always start out saying "My child doesn't have RAD" although some admit their child "just has some attachment issues." The problem is that mild attachment issues can be a precursor to serious RAD behaviors

For more information, read Why Internationally Adopted Children Are at Risk for RAD; Part II: The RAD Continuum

4. Is the risk of attachment disorder related to age at adoption, time spent in an orphanage, or is it just deprivation/abuse/neglect?

It starts with pre-natal care, then moves on to the conditions at birth, conditions in the orphanage, the staff/child ratio and the natural resiliency of the child. Any infant who is neglected when she cries can be at risk for Reactive Attachment Disorder (RAD). RAD can develop within the first few months of life. Many children on the attach-china list who are now being treated for RAD, were adopted as infants. However, the longer a child is exposed, the greater the risk, so there is some correlation between RAD and age at adoption.

5. So, infants can be affected by attachment disorder?

Yes, infants can be affected. The symptoms and severity are harder to detect because infant behavior is much more limited.

Infants who have been abandoned by their birth mothers and then placed in an orphanage where they receive inconsistent care are especially susceptible to attachment disorder because they never had an opportunity to attach to someone. They are at additional risk in utero if their mothers have been anticipating abandonment, because the mothers are already distancing themselves emotionally.

Because children begin to bond with their birth mother while still in the womb, even children who are adopted at birth may be traumatized by the loss of the birthmother and go on to develop symptoms of RAD. This is discussed in "The Primal Wound" by Nancy Verrier.

Daniel Hughes, author of Building the Bonds of Attachment, stated in a workshop that experts are beginning to agree that RAD is most likely to start before the age of one year. The child's most intense need for interaction with the mother is from the ages of four to eight months. During that time, the child wants interaction with her mom 70 percent of the time. Neglect and inconsistency in caregivers during this time are probably the most significant factors in creating RAD.

Please see our Symptom Checklist for further signs.

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6. Would you advise people NOT to adopt from China or other international countries because of these risks?

No. But we advise prospective parents to educate themselves. Love is not enough. While it is possible to adopt a child who does not exhibit attachment problems, parents need to be prepared in case they have to deal with serious issues. Be sure to consider your financial resources and emotional support system before making the decision to adopt. Several list members had to stop working as they realized that the child's stress over separation slowed down her recovery.

We have found that most families do not get adequate preparation for adopting post-institutionalized children. Being a prepared parent makes it much easier to recognize symptoms and find appropriate treatment. Early intervention can prevent a small problem from turning into a large one, and, as with most things, the earlier one intervenes, the easier and more effective the treatment.

In spite of the challenge, most of our parents do not regret adopting their children. This is evidenced by the fact that they are willing to do just about anything and everything to help their children. Some have gone on to adopt again.

7. Don't all kids display some of the behaviors listed on your symptom list at one time or another?

Many RAD or trauma symptoms can be applied to behaviors we perceive in "normal" children, so it becomes easy to dismiss the idea of attachment issues by passing off the behaviors as being 'terrible two's" or "typical 5 year old independence." The difference is in their degree of intensity and the early life history of your child, which is one of abandonment, time in an orphanage and/or foster care, and then adoption - all of which are impediments to attachment. If you feel something is "off" about your child's attachment to you or her behavior, listen to your heart and not to other parents/friends or family members who are not experts in post-institutionalized children. Remember too, that children with attachment disorders often exhibit their worst symptoms to their parents, especially their mothers, while charming others.

8. My child doesn't make good eye contact, but otherwise seems fine. Should I be concerned about her attachment?

Yes. With attachment disorder, lack of eye contact is a message that the child is not comfortable with intimacy. She doesn't want you to see what she is feeling inside, and therefore looks away. Difficulty making and maintaining good eye contact may also be an indication that a child is filled with shame, which is one of the main components of RAD. Attachment activities and attachment therapy with an attachment therapist will increase her comfort level, foster attachment and reduce shame.

However, as with most symptoms of RAD, lack of eye contact can also be a symptom of other things. One cannot make a diagnosis based on just one symptom. It is crucial to look at the whole pattern of symptoms within the context of the total child and her experience. For example, with children who are older at the time of adoption, lack of eye contact may be a learned cultural expectation. It can also be a Sensory Integration Dysfunction symptom, as in the case of many autistic children, who find the rapid movements of the eye disturbing.

9. My child is very strong willed? Isn't this just her natural temperament?

Having a strong will is what enabled your child to survive the orphanage. However, it is working against her as a member of your family. It means she does not trust grown-ups. "Strong-willed" is another way of saying that she needs to be in control, and that is common of children who have attachment problems.

Many child development experts feel that toddlers should be able to obey simple parental instructions like come, stay, and sit down by the time they are 18 months old. If your child is unusually defiant and oppositional, this is a warning sign.

10. My two-year-old is very independent and wants to do everything herself. Friends tell me this is normal and good, but it bothers me. Shouldn't she be more dependent on her parents?

Yes. While age two is certainly a time when children start exploring and asserting their independence, they should still be very attached to their parents, and their mothers in particular. For children who spent time in an orphanage, it is important that they learn to follow before becoming independent. Two may be the right age for most children to begin testing their own abilities, but most post-institutionalized children will not be ready. Remember to parent to the emotional age. Because they missed substantial amounts of nurturing in their early months, you may need to rein them in before they become "too" independent.

Trust your own instincts. If you feel your child is too independent, read more about how to foster attachment.

11. I have discovered that my child has several of the symptoms listed on this site. I am ready to admit that she has mild attachment problems. Won't my just loving her and providing her a good stable home be enough?

Unfortunately, the answer is no. Children with interrupted attachment have learned not to trust that adults will be there to take care of them. They have built defensive walls around inner states of anger, fear, shame and worthlessness. As much as they might want to engage in reciprocal relationships, they can't. They need specific, attachment therapy to change what feels comfortable to them and help them heal the pain that lies hidden in their hearts. To learn more, read Therapy for RAD Children in Bonding and Attachment by Walter D. Buenning, PhD.

The common sense things that help most children are often ineffective for children with attachment problems. Daniel Hughes says that most children do fine with adequate parenting; however, children with attachment problems require extraordinary parenting.

Read more about Parenting a Traumatized Child.

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12. If my child has attachment issues, does that mean she has RAD?

Reactive Attachment Disorder is a continuum. Some people only identify the most extreme end of the spectrum as RAD, but most professionals refer to any attachment disorder along the spectrum as RAD.

Regina Kupecky, co-author with Greg Keck of Adopting The Hurt Child, and their new book Parenting the Hurt Child, says, "I think people get too hung up in what you call it. The attachment line is very long and includes mild, moderate, severe issues. It is like having "a little cancer" or stage 4 cancer....whatever it is it needs to be treated. The length of treatment, success of treatment, extent of damage, type of treatment are all going to be very individual. There is no one thing cures all. Some kids with minor issues remediate on their own with parents, some need mild intervention, some a lot of intervention, some are never going to be healed. Call it whatever just get help."

Many parents worry about the label of RAD and their own preconceptions and fears about what that means. Whether your child has mild or severe attachment issues, she will need special assistance to prevent her from getting worse and to help her get better. Our job as parents is to raise a healthy child, capable of loving and being loved.

13. Does treatment help or is this situation really desperate?

Treatment absolutely helps. Untreated situations can become truly desperate. Although, there may be on-going issues as they enter new stages of development, with proper treatment, RAD children can become very happy, loving and fulfilled. Most of the families on the list who are in treatment are reporting enormous progress.

Attachment Therapy with an attachment therapist, and attachment parenting which provides a high degree of love and limit setting are essential components in the treatment of RAD. Read more about Parenting a Traumatized Child.

14. How do you discipline a child with RAD?

The worst thing to do is spank, time-out, or send the child to her room for bad behavior. This re-enforces her sense of negative self-beliefs and isolation. If a child is acting inappropriately it is because there are underlying feelings that are getting in the way, preventing her from responding the way she should. Your job is to determine the cause of the bad behavior, which is usually a result of angry or hurt feelings inside the child. She needs to know that the BEHAVIOR is unacceptable, but that you still love her. It is important to stay connected with your child even as you correct her. The message you need to send is that no matter what she does, you will always love her, but your job is to teach her the correct way to do things.

When disciplining a child with RAD, parents should quickly reconnect and reassure - within ten to fifteen seconds. This reattunement is provided through touch, eye contact and voice. It is essential, when reprimanding a child, that the parent be holding or touching the child, so that she will be comforted at the same time that she is being corrected. Without the soothing, the child is likely to become overwhelmed by shame or develop a need for revenge.

15. What are time-ins?

As opposed to time-outs where the child is isolated for a few minutes, time-ins involve the child sitting on your lap for a mini holding time or cuddling session. You can also have your child sit right next to you. This way the child is not "abandoned" all over again for a misdeed. Remember that a child with attachment problems feels a tremendous amount of unhealthy shame. Isolating him or her will only deepen this and will probably increase the misbehavior you are trying to correct.

Read more about Parenting a Traumatized Child.

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16. How can I find a therapist who will help me build a stronger attachment with my child?

Lynne Lyon, LCSW, and founder of Attach-China/International, is available via Skype, phone, or in person. If you are looking for someone in your state, refer to the Therapist Listing, or get a referral from other adoptive parents who are in therapy and who you feel have a very good understanding of what attachment issues involve and what the treatment options are. Read as much as you can beforehand so that you understand where your child stands, where you stand and where you want to end up. Screen therapists over the phone. Don't feel like you have to go with the first one you find.

17. What questions would you ask in interviewing therapists to make sure they truly are competent to help a child with RAD and/or Complex Trauma?

Here are some sample questions:

1. Can you give me some examples of the types of children you are treating?
2. How long have you been treating them?
3. What do you consider successful treatment?
4. Where have you trained?
5. What percentage of your practice is adopted/post-institutionalized children?
6. What are the ages of the children you have treated?
7. What kind of tools is the therapist going to give the family to use at home?

It is very important that parents are included in the therapy sessions, since your goal is to have your child attach to you, not the therapist.

18. If I suspect my child has attachment problems, what can I do about it?

Read as much as you can. Do the attachment activities on the web site. Have him or her evaluated and seek help from an attachment therapist who teaches and supports parents in Therapeutic Parenting. Use time-ins rather than time-outs. Limit choices and provide consequences for unacceptable behavior. Make sure you are in control, rather than your child.

If your child is an infant, toddler or preschooler, or if your child has only minor attachment issues, you may be able to address them with attachment activities and Theraplay. However, if these are not effective or if you do not feel comfortable working on your own, seek professional help. It is important that you choose a professional who is experienced in attachment therapy, as others may minimize your concerns, and will not be able to effectively address your child's attachment issues.

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