Attach-China

Frequently Asked Questions

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 Chinese Adopted Childen Are at Risk for RAD
Are there any statistics available on the frequency and severity of RAD in children adopted at less than two years old from China?

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, childen 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.

For more information, read Why Chinese Adopted Childen Are at Risk for RAD
How serious are the cases of attachment disorder that the attach-china list has experienced/seen in adopted children from China?

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 Chinese Adopted Childen Are at Risk for RAD; Part II: The RAD Continuum
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.
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 recent 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.
Would you advise people NOT to adopt from China 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.
Don't all kids display some of the behaviors listed on your symptom list at one time or another?

Many RAD 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 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, epecially their mothers, while charming others.
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 Holding Time 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 Disfunction symptom, as in the case of many autistic children, who find the rapid movements of the eye disturbing.
My child is very strong willed? Isn't this just her natural temperment?

Having a strong will is what enabled your child to survive the orphanage in China. 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.
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 you first build secure attachment before allowing them independence. Two may be the right age for most children to begin testing their own abilities, but most post-institutionalized children will not be ready. 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.
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 child with RAD and PTSD.
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, including Martha Welch, M.D. and Walt Buenning, Ph.D., 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.
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.

Holding Therapy, (aka Holding Time) 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 child with RAD and PTSD.
What exactly is Holding Time? And how does it work?

Holding Time therapy was first developed by Dr. Martha Welch to help strengthen the mother child regulatory bond. In her book "Holding Time" Dr. Welch writes "The child is held in a position that allows the parent to make direct eye contact, while controlling the child's attempts to protest, to struggle, and to escape. The technique anticipates and indeed facilitates confrontation so that problems can be resolved. " There are three specific phases: Confrontation, rejection and resolution. Throughout these sessions, the mother and child both express their feelings at high levels of intensity. This intense physical arousal initiates the release of chemicals from the gut to brain that stimulate bonding. As the mother/child bond is restored or repaired, bad behavior either diminishes or disappears.

Dr. Welch is currently assistant clinical professor of psychiatry at Columbia University where she is studying the physiological changes in the brain that result from holding. In an effort to distinguish her form of holding therapy from 'theraputic holding' that is performed on children by therapists, she now refers to her work as Direct Synchronous Bonding.

One mother writes:
Believe me, Holding Time works. At first I couldn't understand why my daughter was always literally kicking me out of bed but raging at me if I left, because at other times she would tell me that she loved me, and I knew that she did. It made me wonder how she could have RAD. But then I learned that she needs to rage in a safe place. She needs to share the terror that she felt when she was all alone in a crib and nobody came. She needs to have a different outcome where she can re-experience the trauma in my arms. When she avoids me, or acts out, I now understand she is protecting herself from negative feelings. Intimacy was so foreign to her that it felt uncomfortable and scary. Being alone is what feels comfortable to her. Because of her defensiveness, I had to force her out of it.

Martha Welch is always using the examples of how would you react if your child was running into the street or putting her hand in a fire? You'd scream NO and grab her and not let her hurt herself. This is the same thing. You can't let her dictate the terms of love and control in your relationship.

By holding onto your child while she is struggling against you, you are giving her the message that you will not let her push you away -- that you will be there for her always, no matter what she does or feels. Holding Time creates an environment where for the first time, your child is safe to express all of her negative emotions because you are there the whole time, loving her and letting her know you'll love her no matter what.
I have read a little bit about Holding Time. Isn't it abusive to hold a child against her will?

No. It is not abusive to hold a child in a safe way where no one gets hurt. If someone has never witnessed or experienced the positive effects of Holding Therapy, the process can be misinterpreted. It is important to differentiate between hurtful restraint (as in abuse) and loving containment of anger. This concept may be difficult for someone whose only experience of being 'forcefully restrained' is negative. When learning about this therapy, one must learn to distinguish between being mad and being mean. It is ok for parents and chldren to express their angry/hurt feelings, but it is not ok to do it in a mean way.
I want to do HT with my child but I am worried because I know that babies from her orphanage were tied down. Wouldn't HT bring back traumatizing memories of being restrained?

Yes, in a way you are right. Holding Time might bring back traumatizing memories of being restrained. But there is one crucial difference. This time she is here with you, safe in your arms. Tell her that over and over again. Remind her that she is here with you now and you will keep her safe and will never leave her. In order to heal from her trauma, she must face her terror, pass through it and come out safely on the other side. This time the outcome is different. And she will have learned that holding can be a source of comfort and security. If she does not find a way to process her terror, it will be with her always, lurking somewhere in the back of her mind. And you will have no control over when it comes out or how it is resolved.
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.

Here's how one of our mothers handles her 3-year-old:
" I take B by the hands, or if she is being particularly stubborn, by the shoulders, and tell her very firmly what I want (either stop doing something, come when I call, etc.). I then ask her to say, 'Yes, Mommy' in reply to me. Here's where I can tell how stubborn or defiant she's feeling. She will either show a bit of remorse and say, 'Yes, Mommy, I sorry Mommy.' Immediately or she tells me in no uncertain terms, 'No! I no listen to you.' If she complies, then it's over. I hug her and send her on her way. If she's feeling defiant, I tell her, 'Since you aren't listening to Mommy, then I need to Hold you for a while.' We then do a mini Holding Time session. This is not like a normal Holding Time in our family. It is very much 'discipline,' and she usually does not rage at all, she cries more 'pity-party' like and never very intensely. Sometimes I think she likes this Holding so she 'plays' defiant on purpose. I let her go on as long as she wants, she usually complies by saying, 'Yes, Mommy, I listen.' within about five minutes. As soon as she complies, we hug and kiss and she's all cuddles.

"What I have noticed with B, since we do regular Holding Time about two to three times a week and use this discipline Holding Time when needed, she does not tend to 'tantrum' like other two- to three-year-olds I know. The discipline Holding Time seems to ward off any serious tantrum throwing that might develop if I try to reason with her, ignore her misbehavior or let her go on not obeying me. I don't give her choices on behavior. I expect her to do what I tell her. So far it's working great, but knowing how much rage she had inside 10 months ago, it never would have worked without all the regular Holding Time."
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 child with RAD and PTSD.
How can I find a therapist who will help me build a stronger attachment with my child?

Start with referrals 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.
What questions would you ask in interviewing therapists to make sure they truly are competent to help a RAD child?

Here are some sample questions:
a.  Can you give me some examples of the types of children you are treating?
b.  How long have you been treating them?
c.  What do you consider successful treatment?
d.  Where have you trained?
e.  What percentage of your practice is adopted/post-institutionalized children?
f.  What are the ages of the children you have treated?
g.   What kind of tools is the therapist going to give the family to use at home?

You should try to ask for telephone numbers of a few parents you can call, including families who the therapist is no longer seeing (assuming they are cured). Although, because of confidentiality, therapists may not be able to provide you with names of patients. 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.
If you could do it all over again, what would you do with your child from the very first minute to promote attachment and help your child get over the trauma?

We recommend Holding Time, as well as the attachment activities on the web site, and the normal attachment activities that parents do with a baby: singing, talking, touching, reading, bottles. Sleep with her right away. Make sure she is kept facing you in the baby carrier, instead of facing out and use the baby carrier more often. Get a stroller with a reversible handle so that we could look at each other, instead of her facing out. Do not let anyone who is not a primary figure in your child's life hold her or give her hugs or kisses until you are comfortable that she has fully connected with you and your husband/partner.
When should I start doing HT? When we first meet our child in China? Or is it better to wait until she is more used to us?

One mother writes:
In retrospect, I would start as soon as possible. On the one hand, it may be terrifying or threatening to the child because she doesn't know who you are, but if you do HT in a loving and safe way, she will learn that you won't hurt her. This establishes a pattern of trust in your relationship right from the beginning. My only hesitation about doing it with an older child in China, is that you don't know what kind of a Pandora's box you are opening with regards to the child's past. It may also affect other members of your group, and Chinese officials. So you would have to be prepared, and full of confidence to deal with the outcome. With an infant I would not hesitate to do it right away, at the first sign of averted eye contact, back arching, or avoidance.
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. Do Holding Time. Have her evaluated and seek help from an attachment therapist who teaches and supports parents in Holding Time. 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 Holding Time. 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.

Disclaimer

This Attach-ChinaWebsite was founded by a parent for parents of children adopted from China who have PTSD or other attachment issues as a resource for these issues. The content selected for the website is intended to share information about various therapies, and although certain articles speak to the success some families have had with those therapies, the website is not intended as an endorsement of any particular therapeutic course of treatment.

Families with children with possible PTSD and attachment issues are urged to seek medical advice. If a family begins a therapy without medical advice, they do so at their own risk. Children may have unusual or unique reactions to various types of therapies and "one-size-does-not-fit-all" when dealing with these issues. In particular, some parents have noted that children traumatized while in institutional or foster care may have more extreme or unexpected reactions in holding therapy, and therefore, "Holding" should only be done under the supervision of a licensed therapist with experience in this therapy.

This website is not intended to take the place of professional therapy and Attach-China can assume no responsibility for a family's therapeutic choices for their child.