How Can Reactive Attachment Disorder (RAD) or PTSD Be Associated With Adoption or Foster Care Placement?

I Just Want To Give My Child A Safe Home.

Neurobiologically, research has shown that children who experience early trauma or stress, including adoption, experience increased overarousal and hypervigilance, insomnia, physiological anxiety, sensation-seeking, and reduced ability to self-soothe. Additionally, in terms of brain development, there has been evidence of reduced brain size, abnormal organization of brain structures, and smaller underlying structures including corpus callosum, prefrontal cortex, amygdala and hippocampus (associated with anxiety, memory formation, and behavioral regulation, and decision-making); however, if removed early enough and provided with adequate care, some of the brain can regrow to normal size. Per the research, babies can experience changes prenatally (increased cortisol levels in amniotic fluid) if lack of emotional connection or stress from mother in womb and the mothers scent and breast milk has been shown to cause calm and reduce pain. Emotionally, common feelings adoptees have reported include: unloved, unprotected, unsupported, longing, fear, distrust, self-doubt, guilt, anger, broken, isolation, despair, worthless, resentful, jealous, rejected, confused, embarrassed. Adoptees have higher rates of PTSD, ADHD, depression, anxiety, DMDD, RAD, DSED, gender dysphoria, substance abuse, and personality disorders. Its important to note as well that emotional trauma isn’t linear, concrete, or predictable.

As you might imagine, the potential effects of adoption over time are endless, but lets discuss a few. Telling a child they are adopted is almost always a traumatic experience. The older they are, the more traumatic to find out you’re adopted. Many adoptees are “co-dependent” out of survival, seek comfort, control, and stability, need co-regulation as infants/young children. Children feel they also need to be good or they will be abandoned again, can mask true self, become over-compliant, perfectionistic, promiscuous, poor boundaries, require a lot of praise/affection, adopted children are more sensitive to discipline and internalize it more. When young children are placed they often revert to behavioral patterns of prior family. Some adoptees feel they cannot show any sadness because it would be disrespectful or hurtful to their adoptive parents. Being told you are “lucky” to have been adopted can be very invalidating in addition to parents or others telling the child’s adoption story for them, being adopted child is a “gift”, you are another child’s “replacement”, it is “god’s will”, or this was our “last resort”. Children often react emotionally/become dysregulated after visits with biological families. Children may be dealing with being biologically connected to parents who did awful things. Children may have very different relationship with each of their adopted parents (e.g., attach much more so to adoptive father than adoptive mother). Children can have difficulty understanding legality/permanence of adoption, especially if prior placements. Some children have fantasies about bio family and reunification. Not all children/adults desire reunification with bio family. Every time a child is placed in a new home (foster or otherwise) they are re-traumatized. Adoptive parents may feel rejected because of the child’s difficulty attaching, can then affect bond and parenting, children may “test” people to see if they will leave or not. Parents often misunderstand intent behind child’s behavior and expect them to be “tough” or “resilient”. It is often assumed that their bio family “has issues” or is a “sad story”. In future relationships adoptees may: not expect their needs to be met, feel misunderstood, either dependence OR over dependence, indifference, aggression, anxiety, insecurity. Unknown genetics can lead to unknown needs and treatment/support. Some adoptees are retriggered when they have their own children and some feel healing.

We know that early attachment trauma can affect the child’s ability to feel safe, happy, and connected. Disinhibited attachment, as opposed to a secure attachment with a parent, can result in conscious or subconscious search for biological parents, which can affect executive functioning (cognitive, emotional, and behavioral regulation) per the research. Infants may view environment as threatening/dangerous and as a result they tend to either cling (disinhibited, attach too easily, lack of safety awareness, attention-seeking) or withdraw (fear and aggression as well, lack of attachment), result of early exposure to pathogenic caregiving.

So let’s discuss two of the most common “adoption-related” diagnoses as it stands today. There are two types of attachment disorders per DSM-5: Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED). DSED may be associated with a lack of discernment between parents and strangers, while RAD can be associated with hoarding toys/food/other necessities. Sadly, adoption trauma can result in PTSD and serve as precursor to a personality disorder in adulthood if not processed and explored appropriately during childhood. Though adoption can certainly be a positive and a potentially selfless act, especially when the child has connection to their biological family, the origins of adoptions are not so pretty and many children’s experiences have been compromised by those who agreed to protect them or a lack of understanding or good will. Adoption is always perceived as abandonment, regardless of circumstances, it is a continual threat of losing anyone you attach to.

RAD/DSED can be stigmatizing labels that overpathologizes, put the ownness on the child instead of parents (“burden of change” should be on the parents), and these diagnoses may be better accounted for by trauma. I pose the question: are these just differing attachment or personality styles based upon a particular experience or is this truly a “disorder”? Additionally, the “treatment” for RAD can be to force child to attach to adoptive parent in same way as bio parent. Some have recently posited developmental trauma disorder (DTD) instead, which was proposed for DSM5, unique association of the symptomatology with underlying issues linked to caregiver separation and traumatic emotional abuse, including the long-term impact of life adversities, as interpersonal trauma affects emotional and relational self.

Both adoptees and their adoptive parents are more likely to seek mental health services and experience increased inpatient hospitalization. 65%of graduate and 86% of undergraduate clinical psychologists do not recall adoption specific training. Some therapists who are not properly trained may unintentionally fail to help or invalidate if discount relevance of adoption experience, need to make sure attachment focuses on parents and not therapist. Therapy can feel shameful or like punishment because they were “broken”, and when stressed or triggered they may revert back to age at abandonment. In one study, when interviewed, parents felt they had trouble both receiving and giving education about adopted child’s attachment struggles/diagnoses, feel stressed and isolated. Assessments at a single point in time can be insufficient for children who are adopted and can lead to misdiagnosis, need multiple visits and significant collateral information.

But there is so much support available for these children who deserve the best lives possible, as is true for any child on this planet. So here’s what we need to at least move things in the right direction: ongoing training, support groups, psychoeducation from experts, psychiatric care that is affordable and accessible, mediation services, important to acknowledge racial and physical differences, support and immersion in the child’s community and culture of origin, affordable legal representation for birth parents, cross-cultural education, and open record policies. For parents: never pit biological and adoptive families against each other, have open communication about adoption history and origin story, let child find their own identity, show curiosity, compassion, openness, understanding, and self-reflection, understand your own privilege as adoptive parents, never force children to call adoptive parents mom or dad, do not adopt out of birth order, parents to “switch out” and take breaks from parenting, try to give equal attention and care to all children in the family, try to maintain united front (keep in mind that divorce can create retraumatization, though sometimes it is necessary for the child’s well-being), and allow children feel grief/anger/sadness etc. Sometimes can be important for school staff to know child is adopted to best support their needs. It is essential that the child’s therapist be competent with adoption therapy, animal-based therapy (unconditional love and easier to bond), family systems, trauma therapy, EMDR, trust-based relational intervention, dyadic developmental psychotherapy, and sensorimotor psychotherapy have all be shown to be effective in the research.