Help for Attachment Problems in Adoption

By Gloria Wassell, MHC, NCC, Licensed Mental Health Counselor and co-author of Adopting Older Children

Can older adopted children have attachment issues? First, let’s define attachment (or reactive attachment disorder) in the context of the parent-child adoption relationship. What are difficulties in attachment in adoption? Difficulties attaching are often due to trauma or stress early in the child’s life when needs were not properly met. Attachment disorders in adoption may occur when the child is not able to emotionally connect with the caregiver and refuses comforting when needed. In more severe cases, the child may act out aggressively toward the caregiver when being consoled and display an array of other concerning behaviors (more on that in a minute).

What is Attachment Theory in adoption and why is it so important?

Attachment Theory, as described here, explains the infant-mother bond in the earliest stage of life and posits that infants are born with a natural instinct to seek their mother, as an adaptive function for survival. This biological predisposition serves as an innate drive to form human attachment so that an infant’s needs can be met.

Infants are born "wired" to form human connections. Humans are the only species in which offspring need to remain attached with their parent for many years to develop socially, emotionally, physically, cognitively, and in other ways. Although an older child might not require the same level of nurturing as an infant, there is an ongoing need for the parent-child social bond, including contact comfort and protection. This social bond serves many purposes, including as a buffer to adverse experiences.

Does Attachment pertain only to the mother as a caregiver?

While much of the research on attachment has examined the mother-infant dyad for obvious reasons of pregnancy and primary caregiving, there is a branch of research on the father-infant dyad which has identified the benefits of a secure father-child attachment and the importance of paternal sensitivity.

The formation of attachment is a bi-directional process between the parent and child. An infant cues the parent, and the parent then has to respond. Parental sensitivity toward infant cues and signals further influences the quality of attachment in adoption. Infants display cues and signals to communicate their basic needs, such as crying to illicit a response to hunger, distress, discomfort, pain, or a need for proximity and contact comfort.

Parental responsiveness to infant cues shape their development of trust and security in relationships, and improve infant health. In studies of breast feeding mothers, physical contact influences the infant’s nutritional needs via feeding behaviors. Feeding an infant entails a back-and-forth signaling and responding pattern of interaction between parent and infant. This is a form of communication and lays the groundwork for attachment, security, trust, language, and ultimately the child’s ability to form relationships later in life. This is the way attachment styles originate and develop. When this sensitive process is repeatedly disrupted or maltreated, for example, an infant’s basic needs are neglected, problems are likely to occur.

A variety of factors influence the parent-child bond. The parent's attachment style is based on their own individual early experiences and plays a significant role. Consider the impact of a parent who was neglected or abused, or conversely, the parent whose needs were met in a healthy way with warmth and responsiveness.

Thanks to human biology, there is a natural chemical boost that encourages the mother-infant bond by releasing oxytocin to nurture their connection. Oxytocin is also released during positive human interaction such as a hug or kiss, and serves as a buffer to distress. This also plays a role in mother-infant eye-contact, an important nonverbal cue in their dyadic relationship. When babies gaze at facial expressions they are learning patterns of interaction and social cues. Maternal-infant gaze serves as a precursor to language acquisition and as a foundation for socializing. However, individual oxytocin levels vary, and the presence of adverse experiences in the parent's early years can still negatively impact child development.

As the infant’s primal need for connection is evolutionary, critical for development, and necessary for survival, if the attachment damaged or broken, it can be devastating to the child (and parent, depending on the circumstances).

Back to our opening question...

Can an older adopted child have problems with attachment?

You probably figured out the answer is most certainly, yes, it is possible for an older adopted child to experience problems with attachment. Though it should be noted that non-adopted children and anyone can experience attachment problems depending on their circumstances.

Children who become involuntarily separated from their parents are at higher risk of experiencing a traumatic response. Other risk factors include displacement from their home, inconsistent caregiving conditions in foster care or in orphanages, multiple failed placements, loss of personal belongings, changes in schools, and loss of supports from their community. The level of stress for just one of these events can be difficult to overcome.

Pre-adoption stress has been associated with a variety of potential behavior problems. Many older children who are placed for adoption may have life experiences that are not conducive to a healthy attachment. The act of being separated from primary caregivers and family of origin is a traumatic event, often involving a complex combination of emotions including grief and loss. In addition, there is grief from loss of what was familiar, loss of attachment toys and plushies, loss of anything they became accustomed to knowing. Children may be confused about the circumstances or developed maladaptive ways of coping.

You may observe unusual behaviors that once served a purpose in your child’s previous maladaptive environments. Behaviors that are rooted in fears or trauma (for example, hoarding food) may linger long after the child leaves the maladaptive environment (e.g., insufficient food, neglect of basic needs), even when there is evidence the problem does not exist (e.g., food is consistently ample, available, and accessible). Children need time to learn whether or to what extent their needs will be met. Repetition and consistency in caregiving is crucial to building trust and attachment. If your child is not progressing during the adjustment, seek appropriate intervention.

Clearly, there are numerous external factors influencing attachment. There are also internal mechanisms affecting the child’s resilience toward adverse events. Individual genetic and biological influences and neurological development play a role in stress thresholds, sensitivity to change, adaptation, and many other functions. Furthermore, the child’s biology is also influenced by maternal predispositions and behaviors during the prenatal period and in utero.

In measures of temperament, infant studies have identified several dimensions that range from easier dispositions to more difficult dispositions. Some studies show stability of temperament over the first year, while others show malleability of temperament over time. There is a wealth of research examining the effect of infant temperament on caregiver responsiveness. Hence, the parent-infant dyadic relationship is bidirectional. Parental responsiveness is very much influenced by their own personality, temperament, and prior attachment experiences. The nature-nurture question asking which plays a bigger role - genes or environment - has been studied for decades. Depending on the personality characteristic, inheritability does not necessarily outweigh environmental factors. Environmental contributions serve to influence personality and temperament as well.

In addition to variations in individual attributes in both the child and parent, and past abuse or neglect, family constellation plays a role as well. For example, in cases of severe neglect, a child may have been relegated to care for younger siblings, provide food, manage bills, doing laundry, etc. Going from the dependent child into a provider role so prematurely may impact the child’s ability to later depend on and trust others. Sibling position mediates relationship experiences as well, particularly if the child was abused by a sibling.

There are many proximal and distal processes that influence the child and family. Access to resources, availability of supports and services, health care choices, quality of child care, etc. Systems that comprise the wider circle of influence surrounding the child and family include geographic location, cultural factors, political and economic climate, and larger impacts on the child’s ecology. Proximal processes such as supports in the community, neighborhood, and school, therapeutic and emotional supports during stressful times, availability of health care, and connections to community. There are many contextual layers of influence that contribute to a person’s development over time.

For a more complete list of factors affecting a child’s attachment, see Adverse Childhood Experiences (ACEs).

Regardless of attachment style and degree of severity, there is help and hope for many children with attachment problems. The extent to which a child can learn to form healthy emotional attachments can be bolstered by the parenting approach and utilization of proper interventions and supports.

Some older adopted children with attachment difficulties will eventually be able to connect with others and form healthy attachments, and grow to have healthy relationships. Some children will be too afraid to open themselves up to others for fear of being abandoned, and they might be good candidates for therapy. A very small percentage who are diagnosed with Reactive Attachment Disorder might not be able to develop healthy attachments, however this is rare.

Typically, children who are placed for adoption are struggling with feelings of separation and loss from their parents or primary caregivers. This is true even if they experienced maltreatment from their caregivers. Thus, the risk of developing an unhealthy attachment to subsequent caregivers or others in their life increases in children who have a history of maltreatment. In older adopted children risks increased if the child has been in an institution, had multiple placements, and a variety of caregivers. The higher the frequency of each, the higher the risks.

What are some of the symptoms that can be due to attachment problems?

Please note, the presence of symptoms does not necessarily imply there is an attachment problem. Likewise, the absence of specific symptoms does not mean there are no attachment problems. This is a guideline listing potential concerning symptoms to use as a prompt to decide whether seek professional help.

The DSM 5 lists specific criteria for each type of attachment, however this is not meant to be a diagnostic tool. There are nuances and overlapping symptoms with other disorders (e.g., PTSD, Autism, ADHD, Conduct Disorder, etc.) that require professional clinical judgment to diagnose.

Indicators of healthy attachment:

• Responsiveness to others’ emotions
• reciprocity of emotions
• both feel emotionally close
• child seeks and accepts comfort
• child is able to overcome momentary emotional challenges
• the child is able to give and receive affection
• the child’s emotions are consistent with the situation, for example, laughter when something is funny, or sadness when something is sad.the feelings are appropriate for emotional climate
• the child feels understood
• The child is developing trust

Indicators of poor attachment:

• Emotionally detached
• not able to seek a receive comfort
• lacks empathy
• not affectionate
• does not reciprocate emotions
• emotional reaction does not match the situation
• seeking comfort then rejecting it
• inconsolable
• does not seem able to connect emotionally; appears indifferent or aloof
• has poor boundaries - easily approaches strangers or behaves friendly with unfamiliar person,
• separation anxiety as soon as the caregiver is out of sight, even in the house
• does not recognize or respond to others emotional signaling cues (verbal or nonverbal, for example ignores a crying infant nearby and shows no reaction, when angry does not care if someone gets scared or injured

What are the different kinds of Attachment types?

When parent and child attachment styles are mismatch, this is more likely due to the different upbringing and influence. It takes time to understand the child’s model of attachment and learn how to interpret the child’s cues.

This depends which model is being referenced. When reviewing the history of attachment disorders, there have been changes in the detection, identification of symptoms, classifications, and evolution of treatments. According to those following the first model of attachment developed by John Bowlby, secure attachment is optimal but insecure and avoidant attachment patterns are also attachment, just not optimal attachment. The most troubling is disorganized attachment where there is not a pattern; this type of attachment leads to many behavioral and developmental/psychological difficulties.

According to the Diagnostic and Statistical Manual 5th Edition (DSM-5), there are two classifications of attachment disorder types. These are conditions of stress as related to early trauma, neglect, and maltreatment:

1. Reactive Attachment Disorder
2. Disinhibited Social Engagement Disorder

The symptoms of Reactive Attachment Disorder and Disinhibited Social Engagement Disorder are extreme, rare, and controversial.

RAD: Reactive Attachment Disorder

The DSM 5 outlines RAD criteria based on the frequency, grouping, and severity of symptoms. Some of these symptoms include an emotionally withdrawn response toward the caregiver, possibly a violent response toward the caregiver, persistent social and emotional disturbances, lack of empathy, limited positive affect, and unexplained emotions. Children with RAD seldom seek comfort when distressed, or they may demand comfort then reject it. Their emotional responses may appear inappropriate (e.g., laughing during times of sadness), and display emotional bouts that are severe. Proper boundaries may be lacking, for instance approaching strangers who are unfamiliar.

Behaviorally, children with RAD are difficult to discipline, and they may experience social rejection from peers, conflicts with adults, and engage in high risk behaviors. If left untreated, the prognosis for RAD is bleak, with a trajectory toward juvenile delinquency and incarceration.

Although the DSM 5 criteria precludes a diagnosis of RAD if an Autism diagnosis is present, there is research that demonstrates children can meet the criteria for both. The possibility of a co-morbid diagnosis may be possible given the different etiologies of each disorder (neurogenetic vs social-emotional maltreatment).

Whether both diagnoses of Autism and Reactive Attachment Disorder can coexist, discerning similarly appearing symptoms requires understanding the differing pathways by a specialized clinical diagnoses and treatment. There may be interventions that benefit both disorders by focusing on relational synchrony.

Diagnosing RAD is complex and requires the clinical judgment of a licensed therapist who specializes in attachment disorders in adopted populations (for adoptive families).

It’s important to note that not all children who experience these symptoms will develop attachment disorders. And not all children who are adopted are going to have irreversible attachment difficulties.

DSED: Disinhibited Social Engagement Disorder

Children with early disrupted attachment may develop DSED which is a dysfunctional attachment characterized by disinhibition such as approaching unfamiliar adults without proper boundaries and indifference to their caregivers. For example, these kids may seek the attention of others and have no fear of speaking with or leaving with a stranger. Children with DSED symptoms need to be watched carefully when in public to ensure they do not wander off to others.

Comparing RAD AND DSED attachment disorders

Symptoms of attachment disorders have overlap, however the primary distinction between these two attachment disorders is that RAD can be viewed as turning away from others, while DSED is more about going toward others, though both involve unhealthy relationships with caregivers and others.

What can be done to encourage a healthy parent-child attachment?

Healthy adoption attachment methods are important. Many parents’ natural inclination is to believe that their love is enough to help a child out of their traumatic past. While being a loving parent is very important (when love is understood properly) this emotion can actually obfuscate matters with children who have experienced a misuse of the word or concept of love. When adopting an older child, parents need a safety net or parachute to get them through the tough times when children are not responsive to a loving approach. Best intentions can lead us astray if we do not understand the repercussions of our interactions with a particular child’s history of interaction with caregivers, constellation of needs, challenges, and view of the world. For instance, a seemingly harmless action could trigger the child due to a negative association in their past.

While there is not a "one size fits all" approach to parenting, there are parenting methods and strategies which have been studied over time in the adoptive population. Parenting styles are only as effective as the populations in which they were studied. In other words, the efficacy of parenting practices is based on the group that was studied (age, individual characteristics, diagnoses, and other conditions). Identifying the most effective strategies may require a bit of investigating and learning about your adopted child, but your efforts will benefit the entire family and aid in the attachment process.

Your child’s disposition and history will help inform which approach may be most appropriate. Consider temperament, development (this is a better indicator than age), personal difficulties and strengths, and needs.

Certain parenting approaches offer universally beneficial strategies such as Gottman’s Emotion Coaching which offers steps to build emotional intelligence, such as recognizing “bids for connection” and responding appropriately to encourage a healthy attachment.

One of the most effective parenting styles balances warmth and firmness to provides the emotional connection while setting limits.

What can be done to improve attachment during our child’s transition to our home?

• Begin with a comprehensive evaluation of your child to assess every domain of functioning and get a baseline. Pediatricians can help point parents in the right direction.
• This article lists possible questions to ask the doctor
• The medical portion should include a baseline physical and tests for hearing, vision, and all areas of basic functioning.
• Bloodwork, and labs
• Specialists as needed for specific concerns

What can parents do to help their child improve?

Manage parenting stress and seek help and support as needed. Parenting stress can affect the family’s emotional climate and affect attachment patterns. Seek respite when it’s an appropriate time for the child to be left with a trusted, competent person.

Create a adoption transition plan to reduce stress for the child’s relocation into the adoptive family home. There are many ways to do this, such as minimizing activities for the first few weeks, maintaining an available presence, taking time off from work, preparing family members at home, and limiting experiences outside the home until routines are established. For more on how to create a transition plan, seek feedback from other adoptive parents in groups online or in your community, and speak with adoptive professionals.

Establish a consistent and predictable routine. This can be done together with the child if developmentally appropriate. Participation in decision-making and planning can be overwhelming for the child, therefore keep expectations realistic. Kids may resist and refuse a routine, however they will benefit from the structure and predictability.

Develop a flexible schedule, especially at first, until the child’s attachment style and behaviors are better understood. Finding a balance between social events and space that works for the child may take some time. Observe the child’s cues and signals that indicate a need for more space, or more support, or help coping with a trigger.

Maintain a healthy parenting style by balancing warmth and limit-setting, being emotionally stable and emotionally available, predictable, and responsive to the child’s needs and emotions.

Identify low-pressure opportunities to build trust. The child’s perspective matters will guide whether the interaction feels safe and secure. A child with attachment difficulties may have irrational fears of being abandoned or neglected and could misperceive well-intended actions.

Children will have questions about their adoption. Be prepared to provide answers. Use caution early on when deciding how much to share from the child’s past. Modify how much to disclose based on the child’s development and circumstances rather than age. Over time, develop a story for your child. Their adoption story helps them cope and becomes their reality.

View the relationship from the eyes of the child to better gauge their attachment style and learn their cues and signals. Observe patterns of interaction, responses to everyday interactions, and anything unusual such as inappropriate emotional responses.

Promote adoption attachment through shared experiences such as bedtime routines and every day interactions.

Consider the underlying cause of "behavior problems." Children who lived in "survival mode" to cope with difficulties in their previous home environment(s) may develop behaviors, thoughts, and emotions that are no longer adaptive in their new environment. Children with multiple failed placements may not want to "settle in" (emotionally or otherwise) for fear of having to leave.

Learning about your child’s thoughts and behaviors takes time and patience. Your child’s internal dialogue has been imprinted by previous experiences. What may seem to be maladaptive in the current environment (noncompliance, aggression, shutting down, acting out, running away, etc.) might have been highly adaptive in previous settings. Identifying patterns and connecting the dots of a child’s past is not easy and may require professional help to break down barriers.

In the beginning, keep expectations in check. There may be a "honeymoon period" where things may seem to be going well at first. Or in contrast, things may seem to be going horribly wrong at first. When a child and new family are becoming a new unit, everyone needs time to adjust, adapt to each other, and cope with changes.

Expose the child to healthy models of attachment. When your child is ready for social interaction outside the family, choose positive role models to help build social competence.

Building trust and developing a healthy, secure attachment will take time. This requires being consistent over the long-term. Admit mistakes and validate the child’s feelings to modeling flexible emotions and set a tone of openness.

How can I find adoption-competent therapy and support for attachment in adoption?

Finding adoption-competent therapy and support is important in adoption attachment. Begin locating supports and providers before bringing your child home. Mental and behavioral health care is important to have in place, and perhaps begin utilizing to assist with the transition into your home. If you live in an area with few or no supports or services for adopted children, the outcomes can be devastating for families with a child who has severe attachment problems such as these adoptive families dealing with attachment problems.

Establish a network of resources for adoption attachment disorder and maintain a circle of adoptive parents for support and respite. You do not have to reinvent the wheel. Seek input and help from other parents who understand what it’s like to go through the pre- and post-adoption process. They can comment on various strategies and approaches, and may be able to recommend providers and services. Begin with national organizations as they typically already have established networks and local branches available to join.

Seek out adoption-competent professionals who have a history of effectively helping adoptive families. If you’re unable to find adoption competent providers in your area, you may be able to do phone consults and video sessions with professionals who are out of the area or too distant to see in person.

• Start with a phone consult to assess whether the provider is a good match, professionally and personally for your child.
• Prepare questions on a sheet of paper or notepad in front of you so that you can check off questions that have been answered and make notes as you speak. Keep a file for your therapist search. These questions may help you identify whether a particular provider has the necessary qualifications and attributes to work with adopted children.
• Ask the therapists what kind of therapeutic orientation they are specialized in utilizing. Ask if they use empirically-validated therapies. These are also known as "evidence-based." More on that below.

These are a few therapies that may be appropriate for families with adopted children. Their effectiveness depends on the primary presenting problems, such as concerns about attachment:

• Cognitive-Behavior Therapy
• Trauma-Informed Therapy
• Filial Therapy
• PCIT (Parent-Child Interaction Therapy)
• Abuse-Focused Therapy
• TF-CBT (Trauma-Focused Cognitive Behavior Therapy)
• DBT (Dialectical Behavior Therapy)

You can ask the therapist if their approach is "evidence-based" (a therapist who uses research-based interventions will understand these phrases, such as research-based therapy, and empirically-based practices). Ask for details and resources about the therapy. The therapist’s answers will give you an idea of how well they understand the therapeutic approach.

Whether the therapist properly implements the modality of therapy is a different question, thus ask around and read reviews.

Ask which kinds of specific problems do you specialize in treating? (older adopted children, attachment problems, adopted family systems, learning difficulties, identity development in adopted individuals, the specific issues when adopting older children, and any number of symptoms adopted children may experience: anxiety, depression, etc.)

Be leery of antiquated or unsubstantiated techniques, and those that are known to be harmful.

Adoption provider resources are available online to give you an idea of how to navigate services, such as this guidebook which provides some insights into the helping process and lists therapies.

Is there help for my child with adoption attachment issues in the school setting?

This depends on the nature of your child’s difficulties, and to what extent the challenges affect their participation and involvement in school, such as academic supports, social skills, physical development, medical needs, classroom accommodations, and other school-related services or supports.

Speak with a school administrator or counselor about your concerns regarding your child’s functioning at school. Depending on the concerns, the school may suggest having a child team meeting with your child’s team (teachers, principal, school psychologist, special education teacher, etc.) and decide whether to have your child assessed through the school district.

Collaborate on appropriate school supports which may include varying levels of intervention based on each individual student’s needs. In some cases students may qualify for a 504 accommodation plan, or an IEP to be determined through a school based evaluation.

Education laws and regulations are in place to guide this process of ensuring that all children (in the United States) have the same opportunities and access to learning.

Parents have a right to send a request expressing concerns to the school district Special Education Office. Schools have to respond within a certain period of time to evaluate the child. The evaluations are based on areas of concern, at no cost to the family, and are used to identify whether there are needs to provide.

If the child is not improving in the public school setting, the results of the evaluation and concerns are discussed at the IEP team meeting (the parent is just as important a team member as any school staff), then a more appropriate placement can be considered (e.g., smaller class size, special school setting, therapeutic residential school, etc.).

Students and parents are protected by federal and state educational laws and regulations through the IDEA process of establishing FAPE, scheduling IEP meetings, requesting IEEs (when you disagree with the school’s educational assessment results), and managing the child’s IEP (Independent Educational Plan). An excellent resource for education laws and education advocacy is WrightsLaw. The OCR website is also useful and provides information on civil rights.

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