Sunday, May 01, 2016

Attachment Disorder Within The Foster Care System

Attachment Disorder Within the Foster Care and Adoption System
The relationships formed in early infancy and childhood create the framework from which all future relationships will be played out. The cement that holds this framework together is called attachment. When children enter the foster care and or adoption system, the bond that was previously formed is broken. At times this occurs due to a birthparents choice to place their child for adoption, but more often this results from abuse or neglect. This abuse or neglect can lead to the development of various forms of attachment disorder. Attachment disorder is a serious psychological illness that without intervention can lead to detrimental and lifelong effects.  Children in the foster care system are at higher risk for developing this serious illness and care should be taken to not only understand the disease, but to also find ways to help treat it’s effects.
Abuse and Neglect Statistics
The numbers regarding child abuse in the United States are staggering. The National Child Abuse and Neglect Data System (NCANDS) reports that most states recognize four major types of abuse that includes: neglect, physical abuse, psychological maltreatment, and sexual abuse (Child Welfare Information Center, 2010). Neglect is a passive form of abuse in which the victim’s needs are not met by their caregiver (Goldman, Salus, Wolcott & Kennedy, 2003). Physical abuse is when physical force is used to cause harm, physical pain, injury or other bodily harm to the child (2003). Psychological abuse is also known as verbal or mental abuse and usually involves a parent behaving in a way that conveys a feeling of worthlessness to the child (2003). Sexual abuse is sexual behavior with a child that may include fondling, intercourse, rape, incest, sodomy, exhibitionism, sexual exploitation, or exposure to pornography (2003). Using this definition of abuse, they estimate that there were approximately 695 thousand new reports of abuse in 2010. Of those new reports of abuse, 78.3% suffered neglect, 17.6% suffered physical abuse, and 9.2% suffered sexual abuse. Those reports of abuse resulted in over 250 thousand children entering the foster care system, only half of which later returned home. Consistently there are about 400-500 thousand children who are in the foster care system at any given time (Child Welfare Information Center, 2010).
While the statistics show that there is a high prevalence of abuse, Johnson, 2004, points out that the numbers could be even higher as in order to be able to identify abuse, researchers and clinicians need to be able to know who and what to be looking for (Johnson, 2004). Training in recognition of the signs and symptoms of attachment disorder could help improve these numbers as they often point to a larger problem in a child’s family of origin.
According to national statistics, children who grow up in foster care face a bleak future without effective intervention. Forty to fifty percent of children in the foster care system will never complete high school. Without parents to encourage and support them, many lose interest. The other more maladaptive behaviors caused by attachment disorder lead them to thoughts and actions that constantly destroy the world around them. The statistics concerning those children who age out of foster care are even more disturbing, over 66% will be homeless, go to jail, or die within one year of leaving the foster care system (Vacca, 2007).
It seems contradictory that a child who is removed from a home of abuse or neglect would not automatically change behaviors, especially those that prove maladaptive in their new environment. In order to understand this, one must look at the nature of attachment theory.
Overview of Attachment Theory and Attachment Disorder
         In order to understand attachment disorder, one must first know what attachment is. Feldman, 2011, calls attachment the “positive emotional bond that develops between a child and a particular, special individual” (Feldman, 2011, p.179). John Bolby first explored attachment theory in the 1930’s as he studied the effects of maternal loss and a child’s later ability to form relationships (Ainsworth, 1989). Bolby believed that attachment was a biological function that allowed for an infants survival, and provided the means for protection, comfort, and support (Ainsworth, 1989). It is vital that children have a secure base from which to explore the unfamiliar world around them. Aside from this, Chapman, 2002, describes the benefit of attachment, “Attachment with a parent provides the setting in which emotional responsiveness, behavioral purposefulness, cognitive understanding and language development occur (2002).”
Attachment develops in a cyclical process. During the first few years of life an attachment cycle occurs which builds a child’s level of attachment. The attachment cycle is most commonly presented as occurring between birth and age two (Feldman, 2011). Essentially, an infant will express a need, and the manner in which that need is met determines the cycle of bonding that will occur (Ainsworth, 1989). In healthy bonding cycles, an infant expresses a need and their parent meets the need. In turn, the infant is comforted and learns that the world is a safe place and is able to trust and thus bond with the caregiver (Attachment Disorder Site, 2013).
In the disturbed attachment cycle, an infant expresses a need and that needs is met inadequately, if at all. When the need is left unmet, the infant learns that the world is not a safe place and trust does not develop. Without trust, bonding cannot occur. (Attachment Disorder Site, 2013)
This process is repeated many times over during the first years of a child’s life. In the beginning the needs are primitive but become more complex as the child gets older. In time, “the infant begins to organize these expectations internally into what Bolby has termed working models of the physical environment, attachment figures, and himself or herself” (Ainsworth, 1989).
The attachment cycle produces three types of attachment: secure, resistant, and avoidant (Ainsworth, 1989). Securely attached children have a solid base from which to explore the world around them (Ainsworth, 1989). They are confident because their caregivers have provided loving, consistent, sensitive, and responsive care in response to their needs (Inge, 1992). When a child is unsure if their needs will be met, they display a resistant attachment. This is usually related to having parents who respond inconsistently to their needs (1992). Children suffering from avoidant attachment have learned that their needs will be met with rejection (1992). When they expressed a need, their parent rejected their cry for help or attention (1992). After awhile, the child learns it is hopeless, if not dangerous to continue to express their needs.
When The Cycle is Broken
When children enter the foster care system, regardless of the reason, they experience separation from their attachment figure. Under normal circumstances a child is later comforted following the separation from their attachment figure (Conners, 2011). When children are taken from their primary caregiver, they are typically placed within a foster home or other care facility. The new caregivers may or may not be adequate, but even at their best; they are not the person who the child is attached to. A break occurs that the child cannot repair.
The break in attachment is further exacerbated by the abuse or neglect that the child experienced prior to entering care. It is therefore no coincidence that there is such a high prevalence of attachment issues within the foster care system. It is important to note that children who display insecure or disrupted attachment behaviors do not necessarily have attachment disorder (Greenburg, 1999).  However, there is a high prevalence of attachment disorder among children in the foster care system. Zeanah, Scheering, Borris, Heller, Smyke, and Trapani (2004) found that approximately 38-40% of children met the diagnosis criteria for attachment disorder (2004).
What Attachment Disordered Children Look Like
Because of the severity of what happens when children live within the foster care system, it is imperative to look at the symptoms of attachment disorder in relation to the outcomes of children within the foster care system. A child’s inability to form normal and healthy relationships leads to a host of behaviors that range from maladaptive to dangerous. Nancy Thomas, 2005, has written list of symptoms for attachment disorder in her book, When Love is Not Enough. According to her, the symptoms for attachment disorder include the following:
superficially engaging and charming, lack of eye contact on parents terms, indiscriminately affectionate with strangers, not affectionate on parents’ terms, destructive to self, others and material things, cruelty to animals, lying about the obvious, stealing, no impulse controls, learning lags, lack of cause and effect thinking, lack of conscience, abnormal eating patterns, poor peer relationships, preoccupation with fire, preoccupation with blood and gore, persistent nonsense chatter, inappropriately demanding and clingy, abnormal speech patterns, manipulative, triangulation of adults, false allegations of abuse, presumptive entitlement issues, and or, parents appear hostile and angry (p.19).
If one compares the symptoms of attachment disorder, with the known problem behaviors of children in foster care, it becomes very clear that there is a strong link between the disorder and the behaviors of these children. 
It is important to note that there has been much debate as to how and why pathogenic care affects one child and not another, as not every child who is abused or neglected develops attachment disorder. There is some evidence that “a child’s temperament and the specific neurological consequences of chronic or severe maltreatment may influence the way a child responds (Haugaard & Hazan, 2004). Some children simply fair better under pathogenic care.
Diagnosis of Attachment Disorder
Diagnosis of attachment disorder is at times difficult because there are so many comorbid conditions that appear with these children (Hall & Geher, 2003). Children with attachment disorder often end up with a list of other diagnosis that when further examined are encapsulated entirely within the attachment disorder symptom list. This is because the children fluctuate in their behaviors and behave differently depending on whom they are dealing with. One provider may see different symptoms that another provider does not ever notice (Hall & Geher, 2003). Haugaard & Hazan, 2004, also point to the fact that the list of symptoms of attachment disorder is so broad that it may at times be over diagnosed (2004).
            Specifically the DSM-IV requires that children diagnosed with RAD have histories of pathogenic care, meaning experiences of parental abuse and neglect or lack of a consistent caregiver (Hardy, 2007). Because of this, it is logical that children most affected by attachment disorders are those within the foster care system.
Intervention and treatment
Knowledge of the disorder and it’s cause can help professionals and future caregivers lesson the blow and promote healing of those attachment breaks which could lead to a lessoning of the disturbing statistics concerning life after foster care.
The first step in the treatment of attachment disorder is diagnosis. Since there is not a single, comprehensive tool for diagnosis, clinicians oftentimes utilize a variety of tools that when combined encapsulate most if not all of attachment symptoms. Sheperis, Doggett, Hoda, Blanchard, Renfro-Michel, Holdiness, & Schlagheck, 2003 recommend using several reputable assessment tools in addition to parent and child interviews, intelligence tests, and comprehensive psychological histories. The Child Behavior Checklist (CBCL) is designed to asses for abilities and behaviors in a standard format as well as differentiate between children who have and have not received mental health care in the past (2003). The Behavior Assessment System for Children (BASC) is used to assess clients for emotional and behavioral disorders (2003). The Eyberg Child Behavior Inventory (ECBI) and the Sutter-Eyberg Student Behavior Inventory are used to determine the severity of conduct related behaviors of children between the ages of 2 and 17. The Randolph Attachment Disorder Questionnaire is used to determine the severity of RAD specific symptoms, but it must be noted that it is not specific to the DSM IV criteria for attachment disorder. The Reactive Attachment Disorder Questionnaire does include the DSM-IV criteria and is used as well by Sheperis et al, 2003 in their diagnosis of attachment disorder.
Once a child is diagnosed, a treatment program must be started. The goal of attachment therapy is to give the child a “source of emotional security, opportunities for corrective social experiences, and better social skills” Haugaard & Hazan, 2004. While individual therapy is important, because attachment disorder involves their ability to make and form relationships, the relationships in the child’s life must be created and nurtured. For the child in foster care, this means helping them to learn to bond with their foster parent. There has been a great amount of controversy surrounding some types of attachment therapy, including holding therapy and rebirthing (2004). These techniques are described as “coercive” and highly criticized because they are used on children who have already experienced physical abuse (2004). A child who has been physically abused would have trouble distinguishing between holding therapy and the abuse they suffered. Other attachment therapies include a focus on developing a bond with the therapist or other caregivers (2004). Play therapy is another method that is used in working with attachment disorder. It teaches the child better ways to cope with stress and also involved “close, comforting bodily contact” (Haugaard & Hazan, 2004).  
While working with the child is important, it is also very important to support and train those surrounding the child to handle their specific therapeutic needs. Sadly most of those who are tasked with parenting these children have no idea what they are dealing with. What is most disturbing is the knowledge that if they were trained to handle the children in their care with sensitivity, patience, and empathetic understanding, the damage could be prevented or lessoned (Cole, 2005).
Cole, 2005 found that foster parents who are trained to handle the special issues related to children in foster care appear to be better able to aid children in the formation of a secure attachment base. When parents are trained in what it takes to promote attachment, they can utilize those actions to help children adjust to the break in attachment and even promote healing (2005).
            There are times when the child will remain in contact with the offending parent. In these cases it is vital that efforts are made to improve the relationship, although the child’s safety should always remain most important (Haugaard & Hazan, 2004). If the goal is reunification, the parent should participate in therapy sessions and perhaps even get counseling for their therapeutic issues. It is unlikely that a psychologically healthy parent would allow their child to end up in circumstances that would lead to removal from the home. Aside from that, a healthy parent is better able to nurture a healthy child.
            There are many interventions within the foster family environment that can aid in the healing and treatment of attachment disorder. While knowledge of the disorder remains paramount, stress in the home can drastically effect whether or not a child heals, or a foster family is able to successfully care for the child (Haugaard & Hazan, 2004). Foster families who are well cared for are better able to care for the children in their home (Haugaard & Hazan, 2004).
Conclusion
Children within the foster care system have a history of pathogenic care that causes them to be at an increased risk for attachment disorder. Research shows a strong correlation between children in foster care and attachment disorder. This is because the primary cause of attachment disorder is pathogenic care. Children in foster care have experienced this type of environment and have learned behaviors that helped them to survive that once placed into a normal environment cause tremendous upset in their lives.
The providers who work with these children are oftentimes not prepared to handle these children and consequently they are left untreated. Untreated attachment disorder leads to children growing up with lifelong maladaptive behaviors that range in severity from mild to life ending. Further research into diagnosis and treatment is needed to develop a single and comprehensive assessment tool for attachment disorder as well as determine a treatment model that can effectively treat our societies most vulnerable children.
 References
Ainsworth, M. S. (1989). Attachments beyond infancy. American Psychologist, 44(4), 709-716. doi:10.1037/0003-066X.44.4.709
Chapman, S. (2002). Reactive attachment disorder. British Journal Of Special Education, 29(2), 91.
Child Welfare Information Center. (2010). Foster Care Statistics. http://www.childwelfare.gov/pubs/factsheets/foster.cfm. Retrieved March, 1, 2013.
Cole, S. (2005). Foster caregiver motivation and infant attachment: How do reasons for fostering affect relationships? Child and Adolescent Social Work Journal, 25(5-6), 441-457.
Connors, M. E., (2011) Attachment theory: A “secure base” for psychotherapy integration. Journal of Psychotherapy Integration, 21(3), Sep 2011, 348-362. doi: 10.1037/a0025460
Feldman, R. (2011). Development Across the Life Span (6th ed.). Upper Saddle River, NJ: Pearson.
Goldman, J., Salus, M. K., Wolcott, D., Kennedy, K. Y. (2003). Office on Child Abuse and Neglect. A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice. Retrived March 2, 2013 from https://www.childwelfare.gov/pubs/usermanuals/foundation/foundationm.cfm#psychologicalmaltreatment
Greenberg, M. (1999). Attachment and psychopathology in childhood. In Cassidy, J., & Shaver, P. (Eds.), Handbook of Attachment: Theory, research, and clinical applications. (pp. 469-496). New York: Guilford Press.
Hall, S. E. K., & Geher, G. (2003). Behavioral and personality characteristics of children with reactive attachment disorder. The Journal of Psychology, 137(2), 145-62.
Hardy, L. T. (2007), Attachment Theory and Reactive Attachment Disorder: Theoretical Perspectives and Treatment Implications. Journal of Child and Adolescent Psychiatric Nursing, 20: 27–39. doi: 10.1111/j.1744-6171.2007.00077.x
Haugaard, J. & Hazan, C., (2004) Recognizing and Treating Uncommon Behavioral and Emotional Disorders in Children and Adolescents Who Have Been Severely Maltreated: Reactive Attachment Disorder. Child Maltreatment, Vol 9(2), May 2004. pp. 154-160.
Inge, B., (1992) The origins of attachment theory: John Bowlby and Mary Ainsworth.
Developmental Psychology, Vol 28(5), Sep 1992, 759-775. doi: 10.1037/0012-1649.28.5.759
John, P. K., & Kytja, K. S. V. (2008). Reactive attachment disorder in adolescence.  Adolescent Psychiatry, 30, 159-XV. Retrieved from http://search.proquest.com/docview/206091704?accountid=12085
Johnson, C. F. (2004). Child sexual abuse. The Lancet, 364(9432), 462-70. Retrieved I from http://search.proquest.com/docview/199003156?accountid=12085
Sheperis, C. J., Doggett, R., Hoda, N. E., Blanchard, T., Renfro-Michel, E. L., Holdiness, S. H., & Schlagheck, R. (2003). The Development of an Assessment Protocol for Reactive Attachment Disorder. Journal Of Mental Health Counseling, 25(4), 291
Thomas, N. (2005). When love is not enough. A guide to parenting children with reactive attachment disorder. Glenwood Springs, CO: Families By Design.
Vacca, J. (2007). Foster children need more help after they reach the age of eighteen, Children and Youth Services Review, 30(5). May 2008, Pages 485-492, ISSN 0190-7409, 10.1016/j.childyouth.2007.11.007.
(http://www.sciencedirect.com/science/article/pii/S0190740907002149)

"What Is Attachment?" Attachment Disorder Site - Providing Hope and Support. N.p., n.d. Web. 28 Jan. 2013.

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