Out Of The Old Black Bag
OUT OF THE OLD BLACK BAG
Remediating the Past: Reactive Attachment Disorder
Part 2: Society’s Emotional Orphans
Musical Accompaniment: “The Story In Your Eyes” by The Moody Blues.
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“The most important people in a child’s life are that child’s parents and teachers. That means parents and teachers are the most important people in the world.”
Mister Rogers
Every child wants to live in Mister Rogers’ neighborhood — and every adult, too!
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The DSM-V recognizes two distinct forms of attachment disorder: Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED). The first involves the inability to attach to a preferred caregiver, and the second involves indiscriminate sociability and disinhibited attachment behaviors. RAD is the more serious of the two and persists as an entity in spite of the gains made in parenting by the current generation and the research on child development performed by psychologists throughout the globe. The proliferation of substance abuse, poverty, contraction of the extended family, and mental health issues in general have contributed to its perpetuation.
Children with RAD are the emotional orphans of society. Although by diagnostic criteria, symptoms generally develop within the first five years of life, the repercussions can persist (as they did with Winthrop) into the teenage years and even into adulthood. The common variable is failure of emotional bonding with a parent or significant caretaker in the formative years of infancy and childhood due to abandonment, emotional neglect, physical or sexual abuse, mandatory institutionalization, or repetitive placement outside a nuclear family. Even in this modern age of “enlightenment,” as many as 1-2 percent of the population of the United States are affected. The primary diagnostic bifurcation is differentiation from autism spectrum disorders, where the disabilities are far more global. Both conditions involve emotional dysregulation, lack of appropriate eye contact or physical contact, and abnormal social integration. Differentiating the two conditions early on may be impossible since the socialization-related clinical features of RAD in the first year of life closely resemble those of autism:
* Unexplained withdrawal, fear, sadness or irritability
* Sad and listless appearance
* Not seeking comfort or showing no response when comfort is given
* Failure to smile
* Watching others closely but not engaging in social interaction
* Failure to reach out when picked up
* No interest in playing peekaboo or other interactive games
* Unconventional behavior patters
* Failing to seek support or assistance
Many of the older non-autistic children I have striven to support medically at the RTFs have the recurring theme (like Winthrop) of “revolving door” foster care placement. The loving and caring surrogate caretakers can feel betrayed by the child’s emotional “coldness” (through no fault of their own), control issues, anxiety in spite of all efforts to counteract, and consequent disruptive or aggressive behaviors. It becomes confusing when the child’s behavior is more appropriate for age in formal, non-social settings like school or institutions compared to the home. Ironically, the older RAD individuals function better in institutions, where the pressure to “fit in” is more diluted and the expectations of strangers are more regimented and lukewarm; as with Winthrop, the inmate is determined to “cover up” their shortcomings, usually by lying. Unfortunately, as their reputation precedes them and red flags are posted, the potential for a successful adoption becomes attenuated.
Many of the children with RAD are by necessity treated with medications for possible comorbidities contributing to their emotional dysregulation (attention-deficit/hyperactivity disorder, oppositional defiant disorder, depression, anxiety, aggression). However, the mainstay of remediation is intense, long-term behavioral modification and cognitive behavioral therapy, focusing on creating from scratch emotionally healthy bonds and repairing fearful or discomforting relationships between the afflicted children on one hand and empathetic caregivers on the other.
The approach must be multifaceted and include individual psychotherapy, family therapy, special academic education (many of the children fall well behind their peers, especially with the COVID-19 restrictions over the past 2 ½ years), social skills intervention, and prevention of drug and alcohol abuse. Regarding the potential for disabilities persisting into adulthood, the prognosis is guarded. Even with rehabilitation, residual negative personality traits can be detrimental to the individual’s personal and professional growth.
The adoption process is convoluted enough under the best of circumstances. Therefore, on my way to the RTF on the mornings I work there, I remind myself to say a little prayer for Winthrop.
Listen to the tide slowly turning
Wash all our heartaches away
We’re part of the fire that is burning
And from the ashes we can build another day
— Refrain from “The Story In Your Eyes”
Here are two excellent reviews on RAD in children and in teens.
Enjoy all of Dr. Kovatch’s previous essays on The PediaBlog here and here.
source http://www.thepediablog.com/2022/06/09/out-of-the-old-black-bag-24/
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