How to know if your adopted child is still transitioning into your home or suffering from a more serious disorder.

sad girl
Credit: Fancy Photography/Veer

Adopted children have often experienced a great deal of change and transition in their lives. Some may have even experienced serious hardships such as abuse or neglect. A small percentage of these kids can develop attachment disorders such as reactive attachment disorder (RAD) or disinhibited social engagement disorder (DSED). Read on to find out the signs and symptoms of these disorders and the steps to take if you suspect your adopted child suffers from one.

What are reactive attachment disorder and disinhibited social engagement disorder? Reactive attachment disorder and the related disinhibited social engagement disorder are rare but serious disorders that can afflict children who have failed to form normal, developmentally appropriate attachments to a caregiver. RAD causes children to become emotionally withdrawn toward adult caregivers, and children with DSED demonstrate a lack of inhibition when it comes to interacting with unfamiliar adults.

What causes reactive attachment disorders? Both disorders can result when a child experiences extreme trauma, neglect, or abuse and fails to form a connection to a primary caregiver. In the case of adopted children, RAD or DSED can occur in children adopted from poorly run orphanages or institutions, children raised in refugee camps, and children who have experienced neglect or abuse at the hands of their own parents or foster parents. Children who have been moved between so many different homes that they have given up trying to bond with the person caring for them can also be affected.

How common are reactive attachment disorder and disinhibited social engagement disorder? Both disorders are uncommon in the general population though slightly more common in high-risk populations such as adoptees from foster care, institutions, refugee camps, and those with known histories of neglect. According to the DMS-5, the American Psychiatric Association's classification and diagnostic tool, the frequency of RAD in these high-risk populations is less than ten percent while DSED is about twenty percent.

What are the symptoms of reactive attachment disorder and disinhibited social engagement disorder? The Diagnostic and Statistical Manual of Mental Disorders (DSM) describes children with RAD as demonstrating "a consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers" and "a persistent social and emotional disturbance." This manifests itself "as social withdrawal and very shallow emotional responses," says Sean Paul, M.D., a child and adolescent psychiatrist in Gainesville, Florida. In other words, when a RAD child is distressed, she will not seek comfort from a caregiver and may respond negatively to warmth that is given. These signs may be easier to see in an infant, says Kali Miller, Ph.D, a psychologist at Corinthia Counseling Center in Portland, Oregon. "With an infant, you will notice right away that there is a lack of reciprocity, or that when you hold the child, she is extremely rigid or limp."

DSED is defined in the DSM as "a pattern of behavior in which a child actively approaches and interacts with unfamiliar adults in an impulsive, incautious, and overfamiliar way." Children with DSED "approach unfamiliar adults without hesitation and may seek comfort from perfect strangers, instead of turning to their new attachment figure for comfort," Dr. Paul says.

At what age can a child be diagnosed? According to the DSM the symptoms must be evident before the age of 5 but after a child has a developmental age of at least 9 months. "With the older adopted children [who may have either RAD or DSED but have never been diagnosed], it can be a little trickier because they do what we call 'honeymooning,'" Dr. Miller says. "These kids are survivors and since their first instinct is to survive, they seem to transition very smoothly often." But, Dr. Miller says, weeks or months later, when the adopted parents attempt to increase the level of affection with the child through a hug or saying "I love you," the child begins to withdraw and pull back. "These children have had so many broken connections so many disruptions in attachment that they just don't want to do this again."I'm worried that my adopted child may have a reactive attachment disorder. What should I do? "I tell parents to trust their gut," Dr. Miller says. "If something doesn't seem right, then there is no harm in doing a consultation with someone who knows about attachment," she says, ideally a psychologist or pediatrician who has experience with RAD or DSED. Experience with the disorder is key, Dr. Miller says. "Some pediatricians are fantastic about recognizing RAD and making appropriate referrals, but in my experience, many say it is just a stage or that the child is merely transitioning. They are not understanding that time is not going to heal what is going on with these kids."

How are reactive attachment disorders treated? Although an increasing amount of studies have been done on RAD and DSED in recent years, there is still much debate in the medical community about the best form of treatment. Most treatments include developing and increasing the child's sense of security and stability through a great deal of nurturing and a lots of structure. The most established treatments for RAD are dyadic therapy, which focuses on parenting strengths by observing parent-child interactions; infant-parent psychotherapy, which attempts to alter the pattern of emotional communication between the parent and child; and interaction guidance, which uses video and observation to review the caregiver's interaction pattern and then encourages more effective responses, Dr. Paul says. "No one therapy has been proven to be superior to another." Be leery of any practitioner who recommends "therapeutic holding" or "rebirthing therapy," which experts say are controversial, medically unproven, and potentially dangerous. One thing is certain: Treatment plans need to be personalized for each child and include help for both the child and the parents. "Sometimes, when parents already have children who they feel they have parented successfully, they feel confused about why their normal techniques are not working," Dr. Miller says. "But kids with reactive attachment disorder need different strategies than typical kids." For example, using a time-out with a child with RAD may feel like abandonment, so Dr. Miller teaches parents how to use a "time-in," in which a parent removes the child from the activity but holds them to maintain a sense of closeness and security in the midst of the punishment. "I only get to work with the kids one hour a week, so I give the parents techniques and coaching to help them the rest of the week," Dr. Miller explains. "I encourage everyone to get help quickly, because when the children are young, they can often get better so much faster."

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