Why Didn’t The Experts Catch It?

We sought answers from the experts, starting with Casey’s pediatrician, Dr. Johnston, when she was three. We went over her history in the orphanage, her astounding transformation from a quiet, weak, sickly infant to a spunky and spirited toddler. But the out-of-control tantrums and defiance worried us. What were we doing wrong?

Dr. Johnston couldn’t see any signs of trouble (perhaps Casey had worked her charms on the doctor). “Three-year-olds are still trying to get a handle on their emotions and are easily frustrated,” she said, “and Casey was a preemie. They tend to be hyper-sensitive.” She’d grow out of this. She was just a strong-willed child.

This same conversation played out over and over as we took Casey from one therapist to another – she was adorable but just strong willed. Spunky was a good thing! You just need to be tougher with her. Set boundaries. Be consistent.

Yeah, right.

Casey may have been playing all the therapists from the beginning until she announced that she wasn’t going back to therapy and we couldn’t make her. She was right. By then she was 15. We couldn’t slap ankle bracelets on her and throw her in the car. She said she’d call her lawyer if we did (as if).

Now in retrospect, I realize how right Casey had been all along. She called the therapists “idiots.” I’d call most of them ignorant, one professionally arrogant. They had all of the clues but ignored them, treating her instead like any other misbehaving kid without any understanding of where her behavior came from.

How could this have happened?

As I was to learn after Casey died, the effects of attachment disorders were known to a relatively small group of specialists, but they hadn’t made it into the mainstream. The Diagnostic and Statistical Manual of Mental Disorders (the diagnostic bible for therapists) covers hundreds of mental disorders but devotes a scant page or two to attachment. Interviews with adoption therapists revealed that attachment-related issues were given little if any coverage in master’s programs for social work, one prerequisite for therapeutic work.

Rutter_webIt wasn’t until the first wave of orphans from Romania and Russia had been studied over time that mental health experts began to understand the effects of early deprivation in children. One such study was the English and Romanian Adoptee Study in the 1990’s led by Professor Michael Rutter. It began to shed light on the devastating effects of abandonment and long-term institutionalization. According to this study (and much more I was to learn) Casey was at high risk for severe behavioral issues considering the dismal life she lived (despite the best of intentions) before we received her at 14 months. The fact that she was so “normal” most of the time is a testament to her will power, the “strong-will” that the clueless experts referred to.

Assessment! Assessment!

Write this on a blackboard 100 times.

Before I get into this subject, I need to acknowledge something personal. Today is May 3rd. My daughter Casey would’ve been 23 today. It’s one of the two toughest days of the year for me. I went to her memorial bench with her dog Igor to lay some tulips and a can of Diet Dr. Pepper, her favorite drink. Casey is the inspiration for this blog.

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Now back to assessment, and remember I speak as a layperson. This is the starting point for proper care. You can’t address the problem until you know what the problem is, whether it’s attachment, abuse, drugs, bipolar or any of the other hosts of disorders. So many times they all look alike, and often times confused with “normal” behavior.

Not one of the professionals we talked to about Casey suggested any kind of psychological assessment. It had to be a behavioral thing dealt with by discipline.

Hmm.

Ray_Kinney_2The importance of assessment struck me when I interviewed Dr. Ray Kinney, a Director and Staff Psychologist of Cornerstone Counseling in Wisconsin. I stumbled upon him while watching a PBS series called This Emotional Life where he was featured working with a teenage boy adopted from Russia. I was so moved by the program that I reached out to him online and he actually called me! We had a great hour-long conversation.

I learned that he and his wife were both therapists and parents of two adopted Russian children. As they tried to unravel their children’s unusual behaviors as professionals, it became their life work – helping others. This was a common theme I picked up from many of my interviewees – they were almost all adoptive parents or adoptees.

Dr. Kinney had spent over thirty-five years in clinical practice working with a wide range of abused and deprived children in the protective service and foster care systems. His cases numbered in the hundreds. He spoke to me not only about the importance of an accurate assessment but the ability to diagnose children who’d lived in orphanages beyond just attachment issues, a crucial prerequisite to determining an appropriate intervention strategy.

In addition to the effects of institutional deprivation, he claimed that these children might have also suffered abuse, malnutrition or in utero exposure to alcohol or drugs, any of which could have a profound impact on their ability to attach and trust. But an accurate diagnosis was too often compromised by the lack of training among mental health professionals. To the untrained eye, all of these disorders could look the same, resulting in inappropriate treatment.

He said: “All these things come together when you hold in your professional mind that you’re sitting with a child who has loss, deprivations, possible abuse, malnutrition, possible in utero exposure to alcohol or drugs, and how does that affect the child’s ability to attach and trust these parents?”

Hmm.

25 Signs Your Child May Have An Attachment Disorder

Trying to interpret behavioral signs in our children (or anyone for that manner) as a way of predicting potentially dangerous waters ahead can be an infuriating challenge for all but the most seasoned mental health professionals. That was certainly true for us.

Let’s face it. We as parents want our children to be “normal,” so we look for “normal” behavior, we see what we want to see, hear what we want to hear, don’t want to read anything unpleasant. We don’t want to believe that our children have a disorder that stigmatizes them. When Casey’s last therapist mentioned “attachment disorder” I locked onto the word “disorder” and rolled my eyes. Why did everyone have some convenient disorder?

To complicate matters further, many warning signs (whether for attachment issues, bipolar, suicidal tendencies, etc.) can look much like someone acting out in the moment – a toddler’s temper tantrum, a teenager’s defiance. I keep thinking about my friend – a prominent child psychiatrist – who lost his 17-year-old son to the Golden Gate Bridge. Like Casey, his son was set to graduate from high school and head off to an elite private college. If he couldn’t read the signs, how could I?

That doesn’t mean we shouldn’t try to be vigilant, no matter how imperfect the tools that we have to work with.

deborah_gray_00041_xwxvDeborah Grey is a prominent attachment therapist and author based in Seattle. In her 2002 book, Attaching in Adoption, she described a long list of common symptoms that cover the entire spectrum of attachment disorders:

1. Lack of impulse control, self-destructive behaviors, including cutting, eating disorder and other forms of self-harm. Intense displays of anger and rage.
2. Lack of trust in others.
3. Age-inappropriate emotional responses, like temper tantrums in teen years.
4. Marked mood swings.
5. Frequent defiance and opposition. No tolerance for limits or controls. Exploitative, manipulative, controlling, bossy.
6. Frequently sad, depressed, lonely, helpless.
7. Selectively superficial engagement and charm, such as being cool and unaffectionate to parents but charming or affectionate to others.
8. Destructive hyperactivity and destruction of property. Casey battered her bedroom door, stabbed her new IKEA desk with scissors and threw all of her keepsakes in the trash in a fit of rage.
9. Aggression toward others, particularly the parents. How many times had I heard Casey say “I hate you” or “I hate myself.”
10. Consistently irresponsible and forgetful.
11. Inappropriately demanding and clingy. This is a fairly common trait of many adoptees but we never saw it in Casey. She wanted (or claimed to want) independence.
12. Stealing, deceitfulness, lying, conning and manipulating.
13. Hoarding.
14. Inappropriate sexual conduct and attitudes.
15. Cruelty to animals.
16. Sleep disturbance.
17. Poor hygiene and cleanliness.
18. Preoccupation with fire, gore, evilness.
19. Persistent nonsense questions and incessant chatter.
20. Difficulty with novelty and change.
21. Lack of cause-and-effect thinking. Blames others for own mistakes.
22. Learning or language disorders.
23. Perception of self as victim.
24. Grandiose sense of self-importance.
25. Lack of purpose, spiritual faith or remorse (conscience).

Variations of Attachment

I refer to attachment disorders in the plural because they come in many forms and degrees. To confuse things further, reactive attachment disorder (RAD) and attachment disorder are often used interchangeably, at least to the layperson. In this post I’ll try to clarify things. Bear with me here.

Attachment disorder is a broad term used to describe mood, social and behavioral disorders arising from a failure to form normal attachments in early childhood.

Reactive attachment disorder (RAD) refers to a severe disorder affecting children characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way.

Even after seeking clarification from interviews with experts, I failed to see much difference between the two, so I just stuck with the broad term attachment disorder to avoid confusion.

There are four main types of attachment:

1. Secure: The child uses its parents as a secure base from which to explore the world. If the parent leaves, the child becomes upset, but is happy and easily comforted when the parent returns.

secure2

2. Anxious-ambivalent: The child explores little, preferring to remain close to the parents. He or she becomes highly upset when the parent leaves, and resists interaction with the parent upon his or her return.

ambivalent2

3. Anxious-avoidant: Similar to the anxious-resistant type, but the child does not appear to behave much differently around the parents than he or she would around strangers.

avoidant2

4. Disorganized: For those children whose behavior cannot be described by the three main attachment types.

disorganized2

There might even be a fifth type of attachment known as Oppositional Defiant Disorder, an ongoing pattern of disobedient, hostile and defiant behavior toward authority figures which goes beyond the bounds of normal childhood behavior.

What Is Attachment Disorder?

Casey Photos 1991-96_0032           Casey Photos 1991-96_0046

From that first night in Warsaw, we saw things in Casey that took us aback – the uncontrollable tantrums, primal-type screaming, near imperviousness to discipline and lack of coping skills, among other things that evolved as she grew older. But we saw them as nothing more than parenting and behavioral challenges because the vast majority of the time Casey was so absolutely delightful. These were mere distractions that could be dealt with by “proper” (i.e. strict) parenting and discipline.

How wrong we were and how little we knew!

Erika and I hadn’t even heard of the phrase “attachment disorder” until Casey’s third and last therapist brought it up in a debrief session to discuss her refusal to continue therapy. My initial reaction was dismissive – another convenient disorder, just like ADD, ADHD or OCD. Everybody has a disorder! But after getting so close to a proper – if possibly accidental – diagnosis, she veered off in a direction that she was convinced was at the root of Casey’s problems – pot. Indeed, Casey was a teenager who smoked pot just like I did, but that wasn’t the root cause of her problem. Without seeming blasé about teen drug use, I’ve never heard of pot smoking resulting in suicide. That’s straight out of the 1930’s movie Reefer Madness.

Attachment disorder was never again discussed, and the following year Casey was dead. When I revisited that phrase years later while writing my book, I was shocked. It explained everything.

So What Is Attachment Disorder (a/k/a reactive attachment disorder)?

hommedia.ashxThe disorder was an outgrowth of the work, beginning in the 1950’s, by British psychoanalyst, John Bowlby, considered by many the father of attachment theory. He was joined in his work by psychologist Mary Ainsworth. They believed that mental health and behavioral problems could be attributed to early childhood, suggesting that children come into the world biologically pre-programmed to form attachments with others, their form of survival. The main points of their theory are summarized below.

1. Though a child may have multiple attachments, she has an innate need for a primary bond to one main attachment figure, usually the mother. Any breakdown of this maternal attachment could lead to serious negative consequences. The child behaves in ways that elicit contact or proximity to the caregiver. When she experiences heightened arousal, she signals her caregiver (by crying, smiling, locomotion, etc.). Instinctively, caregivers, by creating a reciprocal pattern of interaction, instill in the child a sense of safety in her environment.

Mary-Ainsworth

2. A child should receive the continuous care of this single most important attachment figure for approximately the first two years of life. Bowlby claimed that mothering is almost useless if delayed until after two and a half to three years and, for most children, if delayed till after 12 months.

3. If the attachment figure is broken or disrupted during the critical two-year period the child can suffer irreversible long-term consequences, including delinquency, reduced intelligence, increased aggression, depression, affection-less psychopathy.

4. The child’s attachment relationship with their primary caregiver – the prototype for future relationships – leads to the development of an internal working model with three main features: (1) a model of others as being trustworthy, (2) a model of the self as valuable, and (3) a model of the self as effective when interacting with others.

Mother and Child watching each other

Mother and Child watching each other (Photo credit: Wikipedia)

Attachment disorders arise – simply put – when this primary attachment is broken or was never properly formed in those crucial first years of infancy. Wikipedia defines it broadly as a disorder of mood, behavior and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood, resulting in problematic social expectations and behaviors. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about 6 months of age but before about three years of age, frequent change of caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts.

We’ll discuss how attachment disorders can manifest in children in subsequent posts.