When Love Isn't Enough

By: BROOKE ADAMS

The Salt Lake Tribune

The twisting pinches, the spitting, biting and kicking, the food throwing, the aversion to hugs, the obscene hand gestures and the sexual aggression, the destruction of anything he touched -- all this would come later.

In the beginning, he was just a blond, blue-eyed 3-year-old from Russia in need of a home.

He was one of thousands of abandoned children in foreign orphanages and the U.S. foster care system, and the Sandy couple -- like other parents willing to open their homes and heart -- figured love could conquer about any challenge.

"You've got this life that is so wonderful and you want to share it, to bring this little child into the household, with no idea what the problems can be," says Barbara, whose real name is being withheld to protect the identity of the family.

They didn't know much about how deeply or the myriad ways a bad beginning can affect a child. They had heard only vaguely of attachment disorder, the thing that would forever change their family.

Diagnosis for Debate: An emotional debate about reactive attachment disorder -- its diagnosis and treatment -- is under way following the death of 4-year-old Cassandra Killpack of Springville on June 10 from water intoxication. Adoptive parents Richard and Jennete Killpack, who have been charged with her death, say therapists at Cascade Center for Family Growth in Orem who were treating the girl for the disorder advised them to force Cassandra to drink water as a consequence of bad behavior. The therapists deny that claim.

Cassandra may be the sixth child diagnosed with or with symptoms of reactive attachment disorder to die nationwide as a result of unconventional therapy or at the hands of an overwhelmed parent.

Doctors know what causes the attachment disorder but are less certain how to fix it. Simply put, it happens when an infant fails to form emotional attachments in the critical first years of life. These children typically have been abused physically, emotionally or sexually, and have had multiple caregivers. Often, the children have spent their short lives in an orphanage or bouncing back and forth between a birth mother and state custody or moving from one foster home to another.

Prenatal care may be a factor, too, as birth mothers often drank excessively or abused drugs or were under severe stress. While researchers know the effects alcohol has on fetal brain development, they are now finding that severe early stress and maltreatment also can alter the development of the brain.

By age five, the behavior displayed by such children follows a surprisingly uniform pattern.

"She would let me hold her but it was like holding a block of ice," says Janet Dixon of Fairbanks, Alaska, who adopted a 6-year-old girl from China in 1999 later diagnosed with reactive attachment disorder.

The girl had a robotic demeanor around her parents -- but oozed affection and sweetness toward strangers. Asked to do her homework or help with chores, she would comply but visibly seethe. Dixon remembers attending a school function at which gingerbread cookies were served.

"She would bring me a cookie to eat with the head and limbs all bitten off," Dixon says.

An Old Problem in a New World: In Becoming Attached, author Robert Karen describes a 1760 reference to "foundling home" children who died from "sadness." In the early 1930s, child psychiatrists began documenting problems caused by "maternal deprivation."

Working moms, day care, divorce and abuse are all identified as potential causes of "serious breaks" in bonding in the provocative 1987 book High Risk: Children without a Conscience. The book linked early attachment problems with adult criminal behavior.

In more recent decades, children displaying behavior now attributed to reactive attachment disorder were often labeled bipolar, obsessive-compulsive or oppositional defiant disorder, among other things.

"People were seeing that these kids had problems but I don't think they were connecting it to an early bonding attachment problem," says Gregory Keck, co-author of Adopting the Hurt Child and director of the Attachment and Bonding Center of Ohio.

Two events renewed attention on bonding issues. First, there was the opening of foreign adoptions in the mid-1980s -- up 130 percent in the '90s alone, according to Ronald Federici, a Washington, D.C.-based developmental neuropsychologist who specializes in institutionalized children's issues and is the author of Help for the Hopeless Child.

And second, there has been a push in the United States over the past couple decades to move children out of foster care and into permanent homes.

More families, too, have taken on the troubled children of their own relatives. Two years ago, Cathy Stevens of Layton adopted her brother's three children after they had spent years bouncing in and out of state custody as their father and mother battled drugs and prison time.

Born addicted to crack cocaine, each child has displayed symptoms of reactive attachment disorder. Conventional therapy is helping, but "we have nothing left in our house that hasn't been thrashed or stabbed or broken," Stevens says.

Love Is Not Enough: While some parents are knowledgeable about the potential problems, many aren't or underestimate the challenges they will face. And some adoption agencies are less than forthcoming about a child's history.

Few lay it out as bluntly as the reality can sometimes be, Keck says -- that the most disturbed children may try to have sex with his new siblings or the family pet, or try to set their parents' bedspread on fire or defecate every morning outside the parents' bedroom door.

"The world of adoption is getting more honest. People need to hear the truth," Keck says. "When you get a child in trauma and bring him or her into a family, you are not going to have an easy time because you have a very damaged child who has learned not to trust or cooperate and who believes they need to be in control of everything to keep themselves alive."

Barbara and her husband prove the point. The Sandy couple already had a 9-year-old son when they decided to adopt a boy, a little brother.

Scared by a rash of stories about biological parents in the United State attempting to undo adoptions, they contacted an international adoption agency in Wyoming.

Based on a photograph and a 30-second video, they picked "Adam" and soon were on their way to Russia.

Their first meeting at the orphanage lasted only an hour. "It seemed OK," says Barbara.

The unraveling began at the court hearing. They learned Adam had siblings, that his mom was an alcoholic, that he had been in and out of orphanages. Finally, when he was about one, the Russian government intervened and placed him permanently in state custody.

During the week the couple spent in a Russian hotel with Adam, waiting for paperwork to be finished so they could bring him home to Utah, their alarm grew.

"The first time we took him to eat, he picked up the food and threw it at someone," Barbara says. "He flipped the bird at everyone. A little 3-year-old. It was just a hard, hard time that week."

Her husband wanted to end the adoption right then. Barbara talked him out of it.

When Adam met his new brother for the first time, he spit in his face.

"He was like a little scared animal," Barbara says. Three weeks after returning to Utah, the family enrolled in therapy at The Children's Center in Salt Lake City.

The rejection felt by parents such as this Sandy couple is strong.

"Many parents have a fantasy of a loving relationship, of giving a child everything he or she has ever dreamed," says Doug Goldsmith, executive director of The Children's Center. "They get satisfaction from nurturing, comforting, soothing. With a RAD child, you don't get that."

Simple Goal, Complicated Solution: The goal seems simple: Get the child to attach to his or her parent.

How to do that is the subject of an ongoing debate, one that pits medical doctors against mental health professionals and social workers, as well as parent against parent.

Some researchers are investigating neurofeedback and neurodevelopmental therapy as useful treatments. Experts such as Federici, Goldsmith and Keck advocate multidisciplinary family therapy that may include talk, behavior, play, group and one-on-one therapy.

"We teach parents they need to be incredibly nurturing, to anticipate the child's needs and feelings," says Goldsmith, who estimates his center sees from 160 to 300 children a year with the disorder.

It's "good grandparenting," he says, the sort of things a grandparent does to make a child feel well loved.

In the past, the preferred treatment was not always so gentle. One approach that caught on in the '70s: rage reduction therapy, developed by Robert Zaslow, a professor at San Jose State University, and promoted by Foster Cline at the Attachment Center at Evergreen Inc. in Colorado.

Put simply, it involves a therapist, often aided by parents, either holding a child across his or her lap or lying side by side while provoking the child into a rage by digging into the rib cage and shouting. The theory is that children emptied of rage over their early mistreatment would be able to properly bond.

The treatment persists in derivative forms -- "compression holding therapy," "coercive therapy" and "rebirthing therapy," for example.

And dozens of parents swear by it. Dixon, with the adopted daughter in Alaska, is one. She brought her daughter to Cascade for two weeks of treatment in October. In addition to other therapies, the girl had about 10 holding sessions, including being wrapped in a sheet on one occasion. "I never felt at any time, 'Oh my gosh, what are they doing?' After the first day I could see a difference in her. She'd cuddle in my arms like she never cuddled before," Dixon says.

The expert community backs holding only when it doesn't cause pain or discomfort and is nurturing -- often re-creating the cradling the child should have had as an infant; that doesn't preclude the need for low-level restraint since such children typical have an aversion to being touched.

But compression holding therapy is "out of compliance with professional standards of practice," Keck says.

Federici considers such treatment child abuse. And Goldsmith says, "We don't have any other form of child therapy in which children are being killed."

Seeking Consensus: In June, the American Academy of Child and Adolescent Psychiatrists issued a statement saying there is no scientific evidence backing the use of coercive holding therapies and rebirthing techniques to treat reactive attachment disorder. Such treatments are inappropriate given the nature of the disorder and can have tragic consequences, it says.

Federici belongs to the camp that says attachment disorder "doesn't exist by itself" and is overdiagnosed. Instead, the starting point should be a complete physical, psychological, developmental and neurological workup, which then leads to a diagnosis.

Reactive attachment disorder has become a "gimmick and catch-all for any child who's been traumatized, neglected and abused," Federici says.

The American Psychiatric Association recognizes the disorder as a complex psychiatric condition that can be treated by mental health professionals, though "there are no simple solutions or magic answers."

"It is not a quick fix, it's a quick beginning," Keck says. "Our focus is to put parents in charge of the family, to let the child know that the parent will control and contain them and keep them safe, which is what they did not learn in their few years of life."

Barbara says therapy provided by The Children's Center has helped her family and Adam, now 7, immensely.

"I just love him," the Sandy mom says. "He has got the sweetest heart . . .

"But it is not easy. There is no way we would give him up. But to be honest, we are a little concerned about what the future holds for him and for us."