This blog is my place to vent and share resources with other parents of children of trauma. I try to be open and honest about my feelings in order to help others know they are not alone. Therapeutic parenting of adopted teenagers with RAD and other severe mental illnesses and issues (plus "neurotypical" teens) , is not easy, and there are time when I say what I feel... at the moment. We're all human!

Tuesday, May 21, 2013

Books and Methods Review - Trauma and Reactive Attachment Disorder

The way the world looks at Reactive Attachment Disorder (RAD) has changed over the years. Parents are often told that it is "rare" and most diagnosticians are reluctant to diagnose. The reality is that while it may be rare in the general population, for those of us dealing with adopted and foster children, it is far less "rare" and I would say, it is common. 

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition has changed the definition of RAD. While Reactive Attachment Disorder (RAD) still exists, it is now used to describe "Inhibited RAD." What used to be called "Disinhibited RAD" is now called Disinhibited Social Engagement Disorder (DSED) {More info below}

So What Do You Look For? A List for Recognizing Trauma & Attachment Issues 

The following list of often-experienced behaviors of traumatized adopted children was developed by Dr. Arthur Becker Weidman, Ph.d.  He has studied attachment and complex trauma especially in children who were adopted after the age of 18 months.  If you are an adoptive or foster parent and you can check off more than a few of the characteristics on this list, you may have a child with attachment and/or complex trauma issues.

  1. My child acts cute or charms others to get others to do what my child wants.
  2. My child often does not make eye contact when adults want to make eye contact with my child.
  3. My child is overly friendly with strangers.
  4. My child pushes me away or becomes stiff when I try to hug, unless my child wants something from me.
  5. My child argues for long periods of time, often about ridiculous things.
  6. My child has a tremendous need to have control over everything, becoming very upset if things don't go my child's way.
  7. My child acts amazingly innocent or pretends that things aren't that bad when caught doing something wrong.
  8. My child does very dangerous things, ignoring that my child may be hurt.
  9. My child deliberately breaks or ruins things.
  10. My child doesn't seem to feel age-appropriate guilt when my child does something wrong.
  11. My child teases, hurts, or is cruel to other children.
  12. My child seems unable to stop from doing things on impulse.
  13. My child steals, or shows up with things that belong to others with unusual or suspicious reasons for how my child got these things. {Handling Lying and Stealing}
  14. My child demands things, instead of asking for them.
  15. My child doesn't seem to learn from mistakes and misbehavior (no matter what the consequence, the child continues the behavior).
  16. My child tries to get sympathy from others by telling them that I abuse, don't feed, or don't provide the basic life necessities.
  17. My child "shakes off" pain when hurt, refusing to let anyone provide comfort.
  18. My child likes to sneak things without permission, even though my child could have had these things if my child had asked.
  19. My child lies, often about obvious or ridiculous things, or when it would have been easier to tell the truth.
  20. My child is very bossy with other children and adults.
  21. My child hoards or sneaks food, or has other unusual eating habits (eats paper, raw flour, package mixes, baker's chocolate, etc. ) {Food/ Hoarding/ Diet}
  22. My child can't keep friends for more than a week. {"Kleenex Girls"}
  23. My child throws temper tantrums that last for hours.
  24. My child chatters non-stop, asks repeated questions about things that make no sense, mutters, or is hard to understand when talking.  {Therapeutic Parenting - Nonsense Questions and Chatter}
  25. My child is accident-prone (gets hurt a lot), or complains a lot about every little ache and pain (needs constant bandaids). (Even though he/she may not complain about serious injuries or illnesses - Psychosomatic "Illnesses"}
  26. My child teases, hurts, or is cruel to animals.
  27. My child doesn't do as well in school as my child could with even a little more effort.
  28. My child has set fires or is preoccupied with fire.
  29. My child prefers to watch violent cartoons and/or TV shows or horror movies (regardless of whether or not you actually allow your child to do this). {Media and RAD}
  30. My child was abused/neglected during the first year of life and/or had several changes of primary caretaker during the first several years of life. (This can include multiple or extended hospitalizations)
  31. My child was in an orphanage for more than the first year of life.
  32. My child was adopted after the age of eighteen months (It is possible to have RAD even if the child was adopted at birth - if the child was "pickled" in utero with drugs, alcohol, and/or stress hormones...).
This video gives a good description of RAD symptoms (heads up - lots of Christian faith mentions)
{Marythemom--I do not agree with everything in this video - particularly his claim that EVERY adopted child has RAD. I do believe that every foster/ adopted child has experienced trauma of some sort - just being adopted or in foster care means that there has been a traumatic break from the birth family)}
Attachment Disorders and Post Traumatic Stress Disorder should be viewed on a continuum. 
Symptoms can be mild and healed relatively easily - or extreme and complex.   Post-Traumatic Stress Disorder is usually caused by a significant traumatic event or two.  Complex PTSD is usually caused by years of traumatic events, like a child abuse victim.  Reactive Attachment Disorder is the extreme end of attachment disorders and usually causes permanent brain damage.  {Chronic Post-Traumatic Stress Disorder (C-PTSD)}
 Reactive Attachment Disorder is usually associated with some form of abuse or neglect in the first two to three years of life. This normally involves physical or emotional abuse, abandonment, a drug-addicted caregiver, a sequence of foster placements, or similar emotional trauma. In some cases, children may have symptoms of an attachment disorder if they have experienced divorce, long periods of hospitalization, a parent with chronic depression, or if their brains were altered by the mother's substance abuse.
The most common factor for children with attachment disorders is that in the critical first years of life, either the child did not have the opportunity to bond emotionally with any single individual and maintain that bond, or the child did experience an emotional attachment and then was separated from the caregiver. ~  Strategies for Classroom Teachers of Students with Reactive Attachment Disorder

According to the DSM IV-TR, There are two types of Reactive Attachment Disorder:

 Disinhibited Type:

  • Being way too “cute” and charming, especially as a means to get what they want, whether it is attention or material objects/food.
  • Acts like a baby/uses the “baby voice” and behaves inappropriately younger than their age.
  • Exaggerates about everything, especially their “need” to be helped.  
  • Easily/readily goes off with strangers and/or seeks affection (i.e. hugs) from strangers.
  • Makes friends with a lot of other children (usually younger than themselves), but is not very close to any one of them.
  • Talks a lot – asks a lot of “crazy” questions 
  •  Makes up stories – long, long, stories.
  •  Wants just about everything they see and feels “unloved” when they do not get it.
  •  When they do get the item, pays attention to it for only a short while and then either breaks it or puts it away and ignores it/forgets about it (unless you try to get rid of it, then they desperately love it!). {Decluttering}

Inhibited Type:
  • Avoids relationships and is in a constant pull-push mode with the people trying to be close to him, such as parents.  (Gets close enough to get what he wants, then pushes away again.)
  • Resists affection / stiffens when you try to hug them.
  • Avoids eye contact (unless lying, then will look you straight in the eye and forcefully deny anything, even obvious things).
  • Is always “on guard.”  (Whenever you want to talk with them, they get defensive and think they’re in trouble.)
  • Keeps score.  Knows exactly what he “got” vs. what his brother got for birthdays, Christmas, etc.
  • Has very few friends.  The friends he does have are not all that close.
  • Prefers to be alone.
  • Lies a lot.  “Crazy lies” about things that do not matter.  Believes own lies. {Lying and Stealing}
  • Engages in self-soothing behaviors rather than seek comfort from parents.

Either type:

  • May hoard food, trash. {Food}
  •  May steal. {Lying and Stealing}
  •  May argue about ev.e.ry.thing.
  • May act completely different than the type they usually exhibit.  (Ex.  a disinhibited child may shut down and be surly from time to time, while an inhibited child may occasionally act silly and much younger than his/her age.)

Trauma Triggers

A child whose past trauma is triggered will likely exhibit several of these signs at one time, and they may be even more exaggerated than usual.  Kids can be triggered by sights (violent TV shows, someone who looks like a past abuser, a situation that reminds them of a traumatic event), smells (fried potatoes), sounds (a full laundry basket falling to the ground, a siren, a fire alarm at school, or a loud/sharp yell), and sensory feelings (a certain touch, a particular fabric, cold weather).   

They can also be triggered by "traumaversaries" anniversaries of significant events (like entering foster care), birthdays, and holidays. {Holidays, Birthdays, and Other Traumaversaries}

{How We Handled It - Calming/ Relaxation Techniques Handling Dysregulation/ Meltdowns Handling Rages}

Female Caregivers (the "Nurturing Enemy")
A common defense mechanism for our kids is to try to leave before what they believe is their "inevitable" abandonment by us. Attachment and people loving them is scary. Especially love from the female caregivers - they push us away the hardest of all. They try to move on before things get emotional. Demanding that they want to be put into a new family, foster care, group home... somewhere else, where everything will be "better."

 “Nurturing Enemy” - Our kids tend to behave differently (usually worse) with the female caregiver. In their mind, the mother is the person that hurt them the most, that can hurt them the most. They turn their hatred and loss they feel towards their birth mothers abandonment and abuse toward us. 

Even though we have never hurt them (and never would!), sometimes they get stuck in the past. Often with my kids, it was because things that happened to them before they came to us, got their feelings and the events of their childhood mixed up with me as their mother figure. I know some kids talk about things that they remember having happened to them as a child, as though it had happened recently.

Another thing about their issues with mothers is that we're almost always the ones "forcing" them to deal with attachment and feelings,

Why Does My Child Act Differently With Everyone Else? 

Changes from the DSM IV-TR to the DSM V - American Psychiatric Publishing

DSM-IV  Reactive Attachment Disorder

The DSM-IV childhood diagnosis Reactive Attachment Disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited.

DSM-5  Reactive Attachment Disorder and Disinhibited Social Engagement Disorder

In the DSM-5, these subtypes are defined as distinct disorders: Reactive Attachment 
Disorder and Disinhibited Social Engagement Disorder. Both of these disorders are the result of social neglect, trauma, or other situations that limit a young child’s opportunity to form selective attachments.

Although sharing this etiological pathway, the two disorders differ in important ways. 

Because of dampened positive affect (ex. they don't show their feelings with body language), Reactive Attachment Disorder more closely resembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults

In contrast, Disinhibited Social Engagement Disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have established or even secure attachments.

The two disorders differ in other important ways, including correlates, course, and response to intervention, and for these reasons are considered separate disorders.

Reactive Attachment Disorder - DSM V

Diagnostic criteria for RAD:
  • A consistent pattern of emotionally withdrawn behavior toward caregivers, shown by rarely seeking or not responding to comfort when distressed
  • Persistent social and emotional problems that include minimal responsiveness to others, no positive response to interactions, or unexplained irritability, sadness or fearfulness during interactions with caregivers
  • Persistent lack of having emotional needs for comfort, stimulation and affection met by caregivers, or repeated changes of primary caregivers that limit opportunities to form stable attachments, or care in a setting that severely limits opportunities to form attachments (such as an institution)
  • No diagnosis of autism spectrum disorder

Disinhibited Social Engagement Disorder - DSM V
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:

  • Reduced or absent reticence in approaching and interacting with unfamiliar adults.
  • Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
  • Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
  • Willingness to go off with an unfamiliar adult with little or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.

C. The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of the following:

  • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
  • Repeated changes of primary caregivers that limit ability to form stable attachments (e.g., frequent changes in foster care).
  • Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

E. The child has a developmental age of at least nine months.

Specify if Persistent: The disorder has been present for more than 12 months.

Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Another post on RAD - Psychoses or Syndrome?

Online Support and Resources

Wikipedia definition 
Mayo Clinic definition
American Academy of Child & Adolescent Psychiatry 
Medline Plus

Where can I go for help, support, or to learn more about parenting a child with RAD?

My Top 10ish Things I Couldn't Do This Without
Parenting Attachment-Challenged Children and other Facebook groups!
Christine Moers

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