Implications for practice and research

• Adoptive parents experience significant challenges in caring for children diagnosed with reactive attachment disorder.

• Informing prospective adoptive parents about attachment issues and providing concrete assistance to develop healthy attachment relationships may decrease some of the frustration experienced by parents and children affected with the disorder.

• Future research could address factors contributing to the diagnosis of reactive attachment disorder as well as best practices for ameliorating the disorder.

Context

Reactive attachment disorder is a rare and challenging disorder that affects children exposed to markedly poor care giving environments and impacts on the individuals who ultimately assume responsibility for their care. Children who have had multiple placements in foster care are likely to have experienced multiple attachment disruptions and may be reticent to attempt to attach again. Adoptive caregivers may have experienced multiple losses themselves, such as fertility issues or the return of fostered children to their biological parents, but may have hopes and dreams associated with the experience of parenting children. These and other issues impact on the child-parent dyad's ability to develop an attachment relationship.1

Findings

Four themes were identified: (1) Being unprepared to care for a child with the diagnosis; (2) Being uncertain of one's own ability to parent adequately and subsequent insecurity in one's sense of self; (3) Experiencing many unexpected and overwhelming emotions including anger, guilt, confusion and rejection; (4) Remaining committed to the adopted child despite the challenges. The bonds that developed between parents and their children were fragile and subject to ongoing instability. Although the bond developed at an emotional cost to the parents, they voiced their ongoing commitment to the relationship with their children.

Commentary

Follan and McNamara explored the experience of adoptive parents whose children had been diagnosed with reactive attachment disorder. Many questions remain unanswered. For example, although now seen as counterproductive, in the past, individuals either fostered or adopted a child, but not both, contributing to at least one attachment disruption for the child before permanency. To fully understand the parents' response to the experience of caring for children with reactive attachment disorder, knowing about the child's previous foster care experience as well as the reasons for the initial diagnosis of reactive attachment disorder are important. Although the diagnosis of reactive attachment disorder should only be made when there are specific attachment-related issues, for example the child does not turn to the parent for comfort, at times a diagnosis is made for associated oppositional behaviours rather than for attachment-related issues, per se. Although little is known about the initial diagnosis, thinking on reactive attachment disorder has been refined since the time when these children, many now in their teens, would have been diagnosed.2

Parents’ feelings related to caring for their children were similar to those of their children diagnosed with the disorder in that both felt fear, anger, lack of control, insecurity and sadness. The views of the parents, as reported, contained little empathic appreciation for their children's experience. Perhaps the authors did not ask about this in their interview, and perhaps the feelings of rejection, anger and stress that had arisen over the years made it difficult to consider the child's experience; nonetheless, this is an important area for intervention. Attachment is a dyadic process; assisting parents to understand their child's reluctance to develop another attachment relationship, as well as helping them to find ways to assist their child to establish an attachment relationship would be useful. One study has found that foster parents responded in kind to the child's attachment behaviour; that is, if the child miscued and appeared to not need the foster parent, the foster parent responded by not offering needed comfort to the child.3 An intervention study focused on assisting caregivers to be mindful of the experience of their school age foster child and to develop empathy for the child's experience.4 Such interventions would foster a positive parallel process for parents of children with challenging attachment experiences.