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Late Adoptees From Romaina: Are Attachment Problems Almost Guaranteed?

November 28, 2010

In a word, no. The longitudinal studies conducted over the past decade show otherwise. However, this was a statement made in a 1999 interview by Ronald Federici with the Washington Post with which I am going to take issue.

For all of the older children, beyond adoption age of 2 and 3, attachment problems are almost guaranteed as these children never lived with any type of positive parental figure, nor are they typically afforded proper care. The child under the age of 2 years old stands the best chance and will benefit the most by intensive nurturing and attachment whereas the older adopted child just does not have the ability to benefit from love and nurturing alone.

Considering that the statement was made in 1999, before the longitudinal studies followed these children to see how they actually did over time, it would be understandable that he and others might have made such an assumption that later turned out to be incorrect and I would not be bringing this up, except for the fact that he recently blogged this article in an entry dated November 27, 2010 which makes it appear as if this is current, state-of-the-art research when this is not what the longitudinal data showed. Hence, the need to provide readers with information on what more recent research has found.

I happen to be up on the current research because I recently published a systematic review of the literature on late adoption and attachment disorders, to appear in the current issue of The Scientific Review of Mental Health Practice, which is going to press. For those unfamiliar with the term, longitudinal research means research that follows people through time, rather than just assessing people at one point in time. There is now a series of studies published by Michael Rutter and his colleagues that followed a group of Romainan late adoptees (adopted between the ages of 6 and 42 months — although as I substantiate below, time spent in an institution within that group, did not significantly increase severity of problems) through time.

I will list some references at the end of this article. What a 2007 publication by Rutter and his colleagues showed, which followed the children through age 11, is that while a subset of these children (10% according to parental ratings and 20% according to researcher ratings) do continue to have serious problems, more have either mild problems or no major problems at all. So no, serious damage is not “almost guaranteed” and some children did improve over time being in a stable, loving home with no aggressive interventions.

On the contrary, the research found that children with serious behavior problems were not necessarily shown to have attachment problems and vice versa. There was some overlap, but they are not one in the same. However, some of these children who were carefully assessed by the researchers and shown to not have attachment problems had been diagnosed as having “attachment disorders” that they did not, according to the researchers, actually have. In technical speak, when people with one diagnosis have another diagnosis, this is called comorbidity. For example, a diagnosis of depression is comorbid with a diagnosis of PTSD, but these are clearly two separate diagnoses — someone can have one without the other. This is also the case for Reactive Attachment Disorder and behavioral problems that would likely be diagnosed as conduct disorder or oppositional defiant disorder. There is no evidence that serious behavior problems are caused by attachment problems and indeed, some of the children with serious behavior problems did not even test as poorly attached.

Rutter and his colleagues noted that some of these children had been misdiagnosed by their therapists as having attachment disorders that, according to his team’s assessments, they did not have:

Anecdotally, 10 children in the sample (all Romanian) had received a diagnosis of “attachment disorder” (by professionals) by the time of the age 11 assessment. Of these, three exhibited no signs of disinhibited attachment at age 11 years, four exhibited mild disinhibition and three exhibited marked disinhibited attachment, as assessed by us on the basis of parental reports (p. 22).

This is not surprising, given that many attachment therapists appear to be using instruments such as the RADQ, that have highly questionable reliability and validity. This is a good example of why it is a good idea to question so-called professionals who hold themselves out to be experts and yet are using assessment tools that have not been well tested.

People might naturally wonder, since some of the children in the study were adopted when only 6 months old, if the older children within that group who were adopted later (up to 42 months) and spent more time in an institution with substandard care did worse. That was not the case. Another interesting finding reported in the 2007 report — which reported on data collected from the children at age 11 — is that duration of institutional deprivation, beyond 6 months (children were adopted between the ages of 6 and 42 months) did not significantly increase the severity of problems. When the children were assessed at 6 years old, there was a relationship between severity of problems and years of institutional neglect but that relationship was no longer there when the children reached the age of 11 and were assessed at that time. The six month cut off was based on Bowlby’s theory that it is after age 6 months that infants began to form attachments to a primary caregiver and this research tends to support that, since the problems related to institutional deprivation increased after 6 months — especially between 6 and 12 months. Children adopted after 6 months did worse than children adopted before age 6 months, but it is interesting that length of time of institutional deprivation beyond that did not increase the severity of effects of institutional deprivation, as might be expected. This is a surprising finding, given what some “experts” have led us to believe and a good example of why it is so important to look at the actual research. They note:

We conclude that it takes some months for the effects to be established (because there were none detected with institutional deprivation that did not extend beyond 6 months) but that with any duration beyond that the effects were not greatly increased by the overall length of the period of institutional deprivation (p. 27).

In a 2001 report, Rutter and his colleagues noted that for at least some of these children, “the degree of resilience shown was remarkable” (p. 101).  A study published in 1999 by O’Connor and his colleagues reported that while some parents reported that they did initially experience problems when they first adopted the children, by age four, those problems had been resolved by the time these children had reached the age of four years old.

While the research does show that children adopted later are more at risk for serious problems with attachment and/or behavior than children adopted before the age of six months (who are virtually indistinguishable from children raised by biological parents), being at risk or more likely to have problems does not mean that such problems are almost guaranteed or even more likely than not to occur. This is a statistical confusion many people have in many different areas, not just this one. For example, research has shown that children who grow up in abusive households are more likely to themselves become abusers than children who did not. This does not mean, however, that all or even most children who grow up in abusive homes become abusers. The vast majority do not. It only means that they are more likely to than children who did not. It appears that a similar confusion is occurring with late adoptees. They experience more problems than early adoptees but it does not follow from that, that all or even most experience serious problems.

It also may be that attachment problems have a genetic component. A study of 13,472 twins from a community sample by Minnis and her colleagues revealed a strong genetic influence for both inhibited and disinhibited attachment symptoms, particularly for boys although keep in mind that some of the symptoms assessed for were behavioral problems that are not part of the official RAD diagnosis.

What the literature currently shows is that attachment problems are far from being guaranteed and most recent series of 2010 reports show that causation is very complex. The most common set of attachment problems came under the heading of disorganized attachment, mainly lack of social boundaries and indiscriminate friendliness toward strangers, but not the anti-social behaviors of budding sociopaths so frequently noted by AT proponents who warn parents that if their kids don’t get help, they will grow up to be sociopaths. Those types of behaviors are not in the DSM definition of RAD and there is no indication in any of this research that they should be.

However, some advocates for attachment therapy are still circulating the myth that people planning to adopt internationally or domestic special needs children should expect to have serious problems  which are seen as almost guaranteed. For instance, AT advocate Nancy Spoolstra has  recommend negotiating the funding for an AT intensive for special needs domestic children in advance (she notes this is usually not possible with internationally adopted children). What this could be doing is setting up negative expectations that could, at least in part, become self-fulfilling prophesies. Consider how a child suddenly brought into a new environment, even a normal, well-adjusted child, might react if suddenly brought into a strict, highly regimented boot camp environment where loving expressions are kept to the minimum and strict discipline and unquestioning obedience to rigid rules kept at a maximum. This could be enough to freak out even the healthiest children.

This kind of unwarranted generalization that all late adoptees will have serious problems is the problem that arises when people who have dealt with the subset of children who do have very serious problems make what has been shown to be unwarranted generalizations to the entire population of late adoptees for which problems are far from inevitable. This is a common error made by clinicians who see very disturbed clients/patients and then make the mistaken assumption that those who are coming to them are representative of the population as a whole when they are not. After all, people who do not have such problems are unlikely to ever been seen by mental health professionals, as they would not be seeking help.  In fact, one 2006 study on female Chinese adoptees found that they actually had fewer behavioral problems than the norms on a standardized behavioral checklist. Tan and Marfo found:

  • Chinese adoptees had better behavior adjustment, compared with normative CBCL (Achenbach’s Child Behavior Checklist) data
  • Younger adoptees had fewer behavioral problems than older
  • Neglect predicted CBCL internalizing  (depression) but not externalizing (aggression) behavioral problems
  • No relationship between age of  adoption and behavioral problems

A separate question is what kinds of interventions are helpful for those subset of children with serious attachment and/or behavioral problems. There is, to date, no evidence in the form of well-designed, controlled studies published in peer reviewed journals that the kinds of aggressive interventions being proposed by certain “experts” are helpful. Thus far, what we have are testimonials, anecdotes, authoritative assertions and smear campaigns against those who challenge these claims. There are, however, empirically supported treatments for behavior problems, which seem to be what is experienced as most troubling to adoptive parents and the interventions are respectful and nonabusive (for example, Parent Child Interaction Therapy or PCIT).

Arguments from authority and expertise are not relevant to this discussion because I never ask anyone to just take my word for anything. Instead, I present evidence that people can check out for themselves.

Here are some references for the studies I discussed on the impact of institutional deprivation on children who were later adopted:

Minnis, H., Reekie, J., Young, D., O’Connor, T., Ronald, A., Gray, A. et al. (2007). Genetic, environmental and gender influences on attachment disorder behaviours. British Journal of Psychiatry, 190, 490-495.

O’Connor, T. G., Bredenkamp, D., Rutter, M., & The English and Romanian Adoptees (ERA) Study Team (1999). Attachment disturbances and disorders in children exposed to early severe deprivation. Infant Mental Health Journal, 20, 10-29.

Rutter, M.,L. Colvert, E., Kreppner, J., Beckett, C., Castle, J., & Groothues, C. et al. (2007). Early adolescent outcomes for institutionally-deprived and non-deprived adoptees. I: Disinhibited attachment. Journal of Child Psychology and Psychiatry, 48, 17-30.

Rutter, M. L., Kreppner, J. M., & O’Connor, T. G. (2001). Specificity and heterogeneity in children’s responses to profound institutional privation. British Journal of Psychiatry, 179, 97-103.

Rutter, M. L., O’Connor, T. G., & English and Romanian Adoptees (ERA) Study Team. (2004). Are there biological programming effects for psychological development? findings from a study of Romanian adoptees. Developmental psychology, 40, 81-94.

Tan, T. X., & Marfo, K. (2006). Parental ratings of behavioral adjustment in two samples of adopted Chinese girls: Age-related versus socio-emotional correlates and predictors. Journal of Applied Developmental Psychology, 27, 14-30.

Jean Mercer has also weighed in on this issue on her blog, Child Myths.

For a specific example of an international adoptee who was born in the worst imaginable circumstances in a concentration camp where both of her parents were murdered, spent years in orphanages and was not adopted until she was six years old and yet has thrived throughout her adult life and demonstrated a very high degree of strength and resilience in the face of an all-out smear and harassment campaign by Scientology after she published a critical book about them and is a highly published, successful author who is the antithesis (opposite) of a sociopath, read about the life of Paulette Cooper.

One Comment
  1. Just to point out some important items from Rutter et al’s 2010 SRCD Monograph, “Deprivation-specific psychological patterns: Effects of institutional deprivation”:

    In Chapter IV, “Developmental course of deprivation-specific psychological patterns: Early manifestations, persistence to age 15, and clinical features”, Kreppner et al say:

    “… we note the major changes that took place in the young people with a DSP [deprivation-specific pattern]. … autistic features often (but not always) faded, and problematic social disinhibition as seen in the early years sometimes developed into a strength because the outgoing social style and lack of shyness could be an asset. In addition, several of the young people with DSP showed quite striking accomplishments of a worthwhile kind. A further follow-up will be needed to determine the extent to which these very considerable gains translate into autonomy, independence, and gainful employment and into the development of successful loving relationships. Nevertheless, the findings up to age 15 show that a strong persistence of the effects of institutional deprivation definitely does not mean that the effects are fixed and irreversible” (p. 98).

    Megan Gunnar, in her commentary on the monograph, referred to concerns about attachment among post-institutionalized children:

    “… much energy … has gone into arguments about whether children who are deprived of a consistent attachment figure early in life can go on to form attachment relationships later in development. The ERA study, and others like it… should now put this argument to rest. Specifically, we should not be focused on garden variety attachment problems but ones that fit within the “disinhibited” framework. There are still plenty of questions about whether [disinhibited attachment] is primarily a disorder of the attachment realtionship…. it is not just that these children are really overly friendly with strangers; rather,they seem to have problems with the social boundaries” (p. 243).

    With respect to the gradual changes in the ERA children, the SRCD monograph reminds us of an important developmental rule, similar to that we use in interpreting temperament: characteristics of an individual may change very little with age, but their significance, their effect on others, and the responses they evoke may be quite different for a preschooler and for an adolescent. Similarly, with reference to Gunnar’s comments about DA, it reminds us of the rule that emotion and cognition advance hand in hand during childhood and adolescence, and that it’s a mistake to assume that any form of social behavior involves only one of those domains.

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