Saturday, March 19, 2016
This blog has intermittently been the scene of disagreements between me and certain adoptive parents. Our discussion usually goes something like this:
Parents: Our adopted children are terrible! They lie and steal and are even dangerous to other people. They have Reactive Attachment Disorder, that’s the problem.
Me: That’s not Reactive Attachment Disorder. Reactive Attachment Disorder is [defines RAD as in DSM-5, even in ICD-10 if feeling energetic].
Parents: Yes, they do have RAD! How dare you say it’s not RAD! You’ve never lived with these kids, how would you know?
Me: I just said, those things you described are not the symptoms of Reactive Attachment Disorder. I didn’t say the kids didn’t do the things.
Parents: You ignorant no-good know-it-all, can’t you see that they need their attachment fixed, etc., etc.
Outside of the Attachment Therapy model, I have not seen anyone writing about RAD including antisocial behavior, or even about antisocial behavior as a problem of adopted children. However, while doing a search of the trauma literature for another purpose, I came across an article that focused on antisocial behavior as a particular problem of later-adopted children. The article proposed certain reasons for such behavior and also outlined a possible treatment, which I will describe. I must point out, though, that the article seems to have been published twice in the same journal in slightly different forms, is poorly proofread, and occasionally cites authors who have approved of holding therapy, so I don’t know exactly how seriously to take it. Nevertheless, some interesting points are made.
The article I’m referring to is: Prather, W., & Golden, J.A. (2009). A behavioral perspective of childhood trauma and attachment issues: Toward alternative treatment approaches for children with a history of abuse. International Journal of Behavioral Consultation & Therapy, 5(1), 56-74.
As you can see from the title of the journal, this paper takes a behaviorist position relative to both the causes and the treatments of undesirable behaviors of adopted children. They do not mention Reactive Attachment Disorder. Instead, they list various disturbing and undesirable antisocial behaviors like lying, sneakiness, and manipulation. Rather than proposing that these were caused by a poor attachment history, Prather and Golden discuss how these behaviors could have been rewarded, first by the child’s experiences with abusive or neglectful caregivers, and second by unintentional behaviors of foster or adoptive parents and of other children. Please note that these authors are not blaming the foster or adoptive parents, but pointing out that their natural actions toward the child may reinforce the very behaviors that they want to eliminate.
Prather and Golden point out that adopted children who behave antisocially may appear to lack “conscience” or “attachment”, but in fact they have learned very well from their early experiences with abusive or neglectful caregivers. They have never been punished for lying or using unacceptable language—such actions may have been met with indifference or even amused approval. They may have been taught antisocial rules about hitting as a generally acceptable response, and may have been regularly teased into aggressive reactions by adults. They are likely to have learned to avoid adults in some or even most circumstances, as avoidance has led to the negative reinforcement of evading adult mistreatment. Whether or not they were attached emotionally to their caregivers may be seen as a minor problem compared to their history of learning to behave in “unattached” ways.
It is not surprising that abused or neglected children bring their learned behavior patterns with them to adoptive or foster homes. Once there, it may be a while before the new caregivers realize what undesirable behaviors are going on (and I wonder whether the time this takes is what is perceived as the “honeymoon” period of adoption). During that period, adults in the household may inadvertently reinforce the unwanted behaviors, for example, by failing to notice a lie or a theft. People outside the household are even more likely to provide accidental reinforcement, and this is related to an important issue.
The study of learned behavior has yielded some important principles about how reinforcement affects learning and behavior. The frequency of behavior is raised when the behavior is followed by reinforcement, but there is more to it than that. When the reinforcement stops, the length of time it takes for the behavior to stop depends on how and when the reinforcement used to occur. Paradoxically, when the behavior has been reinforced every time, stopping the reinforcement altogether causes the behavior to drop quickly to a low frequency—but if the behavior was reinforced only intermittently, it will persist for a long time after the reinforcement stops.
Most socially-reinforced behavior is reinforced only intermittently. The abusive and neglectful parents of the now-adopted or fostered children are very unlikely to have reinforced a behavior every time; in fact, they may have been just as likely to punish or to appear indifferent as to be amused or admiring of any action. This means that whatever behaviors were learned by the children, it will take a long time for them to be “unlearned”, especially if they are very occasionally reinforced by well-meaning adoptive or foster parents, by strangers, or by other children who are fascinated by the “bad kid”. Also, of course, some of the unwanted behaviors are self-reinforcing—the child is rewarded by getting the thing he stole or by avoiding punishment by lying.
So, what do Prather and Golden suggest as treatment for the concerning antisocial behaviors? I must emphasize that I have not found any published empirical work that they have done, but they made some suggestions that may be fruitful. Much of the focus is on “catching them being good”: encouraging the family to put less stress on “unattached” behavior and more on times when the problems are not apparent, and especially on ways that problems have been solved and parents have managed not to reinforce unwanted actions . Identifying antecedents, or triggering situations followed by unwanted behavior, can help anticipate and control how the child acts. (For example, does the child act up when the mother goes out without telling him she is going?) Acknowledging and paying attention to negative feelings is another important item, especially as the children may have become numb to their own feelings and therefore fail to experience or to anticipate a sense of guilt or fear of punishment. As Prather and Golden point out,” Unlike traditional attachment based family therapies, which often interpret verbal information in terms of underlying emotional dynamics, the rational cognitive emotive view of human behavior focuses solely on the causal sequences of a child’s experiences and perceptions, and the impact that the child’s negative thoughts concerning trauma have on the role of emotion in behavioral causation.”
Again, there does not seem to be any new evidence about how well this approach can be made to work. And those who are committed to an all-attachment, all-the-time perspective may say, “that’s just treating the symptoms!” But, to quote Nicole Hollander’s “Sylvia”, I might respond: Words to live by!
Tuesday, March 8, 2016
Far, far be it from me to imply that lead poisoning in infants and children is a minor problem, but I feel uneasy about the repeated declarations that children exposed to lead in the environment suffer “irreversible” effects. This I find especially worrisome when there is stress on mental retardation as a possible outcome of lead exposure—to say that mental abilities have been irreversibly affected when infants and toddlers are lead-exposed may in some cases be correct, but ignores the many factors that work together to determine an individual’s mental development. How awful it must be for parents of lead-exposed children to encounter these statements and know that people have essentially disposed of their children as beyond help!
The dramatic statements about lead exposure remind me irresistibly of the “crack baby” concept of the 1990s, when headlines regularly stated that children who had been exposed to crack cocaine prenatally were hopelessly ruined. That did not turn out to be correct, and with proper care given to lead-affected children, the present claims will probably not be true either. Naturally it would have been far better if the children had not been exposed to lead to begin with, but they can be helped to develop at normal levels or close to them. This statement applies not only to the children of Flint, whose water supply was contaminated, but also to the many children in the United States who are exposed to lead in paint, dust, and so on in their own homes.
To support this statement, I am going to refer to a document produced by the Centers for Disease Control, “Managing Elevated Blood Lead Levels Among Young Children” (www.cdc.gov/nceh/lead/casemanagement/managingEBLLs.pdf).
Where children’s blood lead levels are very high, the CDC document recommends chelation therapy, a technique that chemically removes lead from the child’s body. (Please note that while this method is necessary and effective for management of heavy metals poisoning, it is most inappropriate and should never be used for treatment of autism or related problems!) The document points out that chelation should be used with caution and that primary care providers need to seek the help of experts. “A child with a [elevated blood lead level] and signs or symptoms consistent with encephalopathy should be chelated in a center capable of providing appropriate intensive care services!” (! in original; this treatment is nothing to take casually—JM). If the treatment is done with oral chelation agents with the child as an outpatient, the dosage needs to be carefully monitored, and the treatment needs to be done in a lead-free environment.
Children with elevated blood lead levels often have inadequate nutritional intakes of iron, calcium, and vitamins, and nutritional changes have been recommended as ways to prevent absorption of lead or to combat its effects. However, it is not at all clear that nutritional factors affect blood lead levels; it may simply be that children whose families live where lead exposure is likely also have families who do not have access to healthy food or information about child nutrition. Nevertheless, improving children’s early nutrition can be an important step toward good child health and development, both physical and intellectual. Low levels of protein intake and lack of iron are associated with problems of brain and mental growth, especially when they occur in the infant, toddler, and preschool years. Giving children adequate diets is a way to fight mental retardation, even if it does not actually lower blood lead levels. The CDC recommends giving pureed meat to infants as soon as they are developmentally ready, and giving red meat to children once a day. Dairy products and fruits or fruit juices several times a day are also recommended. (Minimizing fatty snack foods is also a good idea, in that it will increase children’s appetites for nutritious foods that may be of less interest when calorie-rich snacks are available.) In order for many parents to assure good nutrition to their children, they need to have not only enrollment in WIC, but access to grocery stores that offer a variety of foods at reasonable prices.
To ensure that each child reaches the highest intellectual level he or she is capable of, high quality preschool programs are of great importance whether or not children have elevated blood lead levels, and it’s possible that such programs can make the difference between moderate retardation and fairly normal achievement for some children, if they are combined with other ways of treating lead exposure. The CDC document also suggests that developmental monitoring is needed for older children who have had elevated blood lead levels in early life. These need to continue into school age, with times of transition like first grade, fourth grade, and seventh grade getting most attention. Children who are inattentive and distractible will need help in order to have the maximum benefit from school.
To summarize, we have a number of ways to encourage good development in children who have been exposed to lead. The lead exposure may be “irreversible”, but a poor developmental outcome is not inevitable, and the worrisome trajectory present when no interventions take place can be reversed to a greater or lesser extent by help we know how to provide. What is needed, of course, is the political will and the funding to put these interventions in place. In the case of Flint, if the right decisions are made, the interventions could begin almost at once, while replacement of water pipes will take years. Similarly, when lead exposure comes from old paint, interventions can be of help now, while actually removing lead from houses can take many years—the process, indeed, can create even more dust and lead exposure than already exist.
Do I hear any candidates for president talking about this? Not really…