The DSM-IV indicates that Reactive Attachment Disorder (RAD) may arises from the “repeated changes of primary caregiver that prevent formation of stable attachments (e.g. frequent change in foster care.)”
The Assessment of Bonding
In addition to the roles of diagnostician and therapist, the mental health professional may be asked to assess bonding. The details of bonding are reasonably well elaborated out in the psychological literature, in the guidelines of state welfare departments, and by common sense. As noted in Chapter Two, however, the lack of a clear definition of bonding has led to a smorgasbord of unfocused data-gathering. Too often, assessments have used a variety of processes and techniques rather than focusing on bonding, its definition and its objective criteria.
The first and obvious step in conducting an assessment is to know what you are assessing. The evaluator must have a clear definition of bonding as his template. Then the assessment should answer the simple question: Is this child bonded to these parents? The procedures employed and the data collected should be relevant to answering this question.
A thorough and professional evaluation of bonding will gather information about the child’s daily living from five or more sources.
- Review all available documents, including the foster parents’ journal, child welfare records, court documents, reports from physicians, therapists, and other persons with relevant knowledge. In addition to pinpointing the time in the foster/adopt home, these documents and reports should provide information related to the various objective definitions of bonding.
- Obtain collateral information from extended family members, neighbors, babysitters, teachers, and any others who might have had the opportunity to observe the child with this family. Is the child perceived as a member of the family? The wisdom of the larger community is a valid way to assess bonding.
- A detailed written developmental history provided by the foster parents will offer data on the child’s growth and development, as well as the child’s behavior, family situation, and other circumstances. The history can also be offered as evidence on how well the foster/adopt parents know the child, an important demonstration of the reciprocal definition of bonding.
- Establish a developmental age. A measure of the child’s developmental age can be important to document the child’s special needs which would qualify the family for post-adoption subsidies. Equally important, when compared with the child’s development at the time of placement, the developmental age can be used to document the child’s progress while in the foster/adopt home. A strong argument can be made in court to “let well enough alone.” The Vineland Social Maturity Scale is one acceptable test to establish a developmental age. Other equally good checklists and test instruments are available for this purpose.
- Child behaviors can be documented by various instruments and research-based checklists that demonstrate bonding. Many checklists exist which provide a good review of those behaviors which research has identified to indicate bonding. Two good examples are the Randolph Attachment Disorder Questionnaire (Evergreen Attachment Center in Colorado) and Keck’s list of attachment disorders from the Ohio Attachment and Bonding Center. The Groves Bonding Checklist (GBC) includes many of the most important bonding behaviors. (See Appendix F.)
- Projective techniques can be introduced to elicit emotions below the surface. The child is presented with a neutral but stimulating object or task and asked to respond. Since the stimulus admits of many possible variations, the child must complete the task in his or her own unique way. The evaluator should structure the situation so that the stimulus will evoke a response about relationships and personal connections.
- Drawings are a popular procedure. The authors use a series of three drawings with no leading hints. The child is requested in order to: “Draw Anything. Draw a Whole Person. Draw Your Family.” Obviously, it is of interest whom the child places in his or her family and who is next to whom. Drawings could also be requested to show the child interacting with siblings or with any and all of the significant adults.
- Stories are also helpful. The evaluator may suggest a family theme. Or show the child evocative pictures about relationships and request imaginative stories. Magazine ads that suggest attachment and family issues might be used to elicit stories.
- Sentence completion tests are frequently used to extract hidden feelings. The evaluator asks the child to complete a series of neutral phrases. The half-sentences should reflect the evaluator’s desire to learn more about the child’s relationships. Opening fragments such as “I am____” “I am afraid____” “I am happy when____” “I wish____” “My family is____” “I don’t care____” “My dad____” “My mom____” The possibilities for encouraging useful information about the child’s ability to connect are limited only by the imagination of the evaluator.
- First-hand observation of the child in the presence of the foster/adopt family is essential. The evaluator might meet with the entire family for several hours in his or her office playroom. While discussing the situation with family members, the evaluator has the opportunity to observe the interactions between the child and family members in free play. A visit to the home is even more informative.
- A semi-structured dyadic interview can be quite helpful by moving beyond free play. Stokes and Strothman (1996) routinely set some specific parent-child tasks. The parent may be asked to groom the child, to teach the child something new, to share a small meal, to leave and come back, to play a game together, to discuss something important or difficult, to make up a story together, to plan an activity together, and so on. The evaluator then has the opportunity to observe what happens in specific situations.
Once the information has been collected, a written report should follow. The presentation of a meal is as important as the food itself, as any good chef will attest. The same is true of a Bonding Assessment. The evaluator must present a clear and well-organized report. Writing a good report and presenting the factual information in a concise and compelling way is the other half of conducting a thorough evaluation. The evaluator must take as much care to write a thorough report as he or she did to conduct the evaluation.
The welfare department and the court will make their decisions based in good part upon the written report. The evaluator’s report should be available for the judge to review after his or her memory of the oral testimony may have faded. Judges read. A well-documented, objective, fact-focused, written report to the court is very important.
A good written bonding assessment has six parts: problem, methods, results, discussion, conclusion, and research.
The report should begin with a brief statement of the problem, noting that the family has had the child in the home for a specified period of time, and that the family wishes to provide this child with a permanent home through adoption.
A list of the materials reviewed and the procedures accomplished should follow in the methods section.
The section on results should define bonding, giving research support for the definition and sub-definitions. The four specific ways to define bonding mentioned in Chapter Two should be fleshed out with the factual evidence provided by the data obtained in conducting the actual assessment. The facts should be allowed to speak for themselves. The bonding evaluator needs to line up the data in relation to the four operational definitions of bonding.
Time together: How long have the parents and child been living together?
Behavior: What behaviors does the child show?
Reciprocity: How do the parent and child interact? What long-term commitments are the parties willing to make to each other?
Community perception: What does the community think?
The discussion section may contain the reflections of the evaluator. Opinion should be reserved for this section and kept separate from the facts.
In the conclusion to the evaluation, a simple statement should be added stating whether bonding has or has not occurred.
If bonding has occurred, the research and current statistics should be provided at the end of the report, telling what happens when bonded relationships are severed. The younger the child is, the more lasting and destructive the consequences of termination can be. Removing a child from bonded relationships has been compared to the loss of a spouse, brain surgery, or the death of a parent. The written report should indicate that the research is unequivocal in statistically documenting a dramatic increase in childhood and adult psychiatric disorders following the loss of a bonded relationship. Reactive attachment disorder, developmental delay, oppositional defiant disorder, AD/HD, and learning disorders have all been linked to disruptions of bonding and may occur soon after such a loss. Sometimes, however, the impact is delayed and shows up in later life with an increase in the likelihood of adult mental illness, homelessness, crime, and poverty.
Bonding has been defined and the serious consequences that may occur when it is interrupted have been presented. Now it is time to go to the welfare departments and courts, those institutions that are trusted by society to watch out for foster children.