Hug the Monkey

For Orphans, There's a Critical Period for Nurturing

In the United States and some other countries, there's awareness that babies in orphanages need to have a primary caregiver -- someone they can bond with. If they don't, they will likely grow up with many psychological and cognitive problems. Babies need loving touch for proper brain development and to develop the oxytocin response that will teach them to bond with others.

The foster care system in the United States is far from perfect -- far, far from perfect. But many nations still have a policy of caring for orphans in institutions, rather than in foster homes. It's partly a question of resources; in an institution, one person can care for many more children.

Researchers from the University of Maryland, led by Nathan Fox, just published the results of a years-long study in Romania in which they compared the development of children in orphanages to those in foster homes.

In one orphanage in the study, the ration of caregiver to children was 1 to 22. If each worker worked an eight-hour shift, she could spend less than 22 minutes a shift on each child. Think about a baby who is changed, fed and touched for no more than one hour each day.

The researchers moved half of the 156 children in the study into foster homes and left the rest in institutions. They could do this ethically because there was no foster care system in Romania at this time -- they had to set one up.

According to the article in Science Daily,

The main findings from the study confirmed earlier results that "children reared in institutions showed greatly diminished intellectual performance relative to children reared in their families of origin." Further, children who were randomly assigned to foster care experienced "significant gains in cognitive function."

They didn't look at attachment, but certainly, the longer the children stayed in the institution, the more attachment problems they had. These are expressed in what we now call reactive attachment disorder, oppositional defiance disorder and post-traumatic stress disorder.  (Institutionalized babies develop PTSD because their bodies instinctively "know" that if they're separated from their mothers, they will die.)

The researchers also found that 24 months was the critical age for children to benefit from placement into a foster home.

But, the sooner the better! And of course, adoption into a permanent home is the best outcome.

Retraining the RAD Brain

I published a story today in the East Bay Express, called When Love Is Not Enough.

The story uses the experiences of two local families who adopted children from overseas to discuss some of the therapies being used to retrain the brains of kids with attachment disorder, PTSD and other abnormalities of brain development.

I didn't get into the oxytocin response too much -- it's too complicated and not the focus of the story. But you can look at the therapies discussed -- attachment therapy, neurofeedback and neurodevelopmental reprogramming -- as ways of building the oxytocin response in the brain.

When Does Attachment Disorder Happen?

In an interview with Babble.com, Jane Aronson, the pediatrician known as the Orphan Doctor, talks about foreign adoption, something she strongly advocates. Aronson is pediatrician to movie star adopters including Angeline Jolie.

In the interview, Aronson points out that adoptions of older foreign children can be very successful when the child was raised by a family, but then lost his parents to AIDS, war or other misfortune. She gives a helpful analysis of adoption services in various countries.

Aronson certainly is highly experienced in overseas adoption, through her organization, Worldwide Orphans Foundation. She makes one strange and really inaccurate remark, however: She claims the science shows that attachment disorder is mostly the result of brain damage or brain chemistry imbalances in the womb.

She told the interviewer,

And attachment likely has more to do with brain damage that occurs during the pregnancy, due to malnourishment, exposure to toxins in the environment, infections during the pregnancy, exposure to alcohol and drugs and smoking. All of that conspires to cause damage to brain structures that are involved in the actual chemistry and physiology of attachment. So when people use this sort of artificial convention of saying, you know, "You gotta get 'em by three, or else they're ruined," I think that's also not taking into consideration that attachment likely has to do with brain chemistry during pregnancy.

While it's accepted that a hostile womb environment -- a mother who takes drugs, who doesn't want the baby, who's being abused -- can make the baby hyper-vigilant and hyper-reactive before he's born, neuroscientists like Bruce Perry who study disordered kids are convinced that not only abuse but also neglect and simple lack of attention after birth can create post-traumatic stress disorder, or PTSD.

In the comments on a blog summary of the interview, most people think Aronson is full of it.

For the perspective of a neuroscientist who studies traumatized children, read this interview with Michael de Bellis of Duke University.

See also RAD Epidemic in Russian Adoptions?

Saving a Troubled Adoption

When I started this blog more than two years ago, the severe behavioral problems that adopted kids and their parents struggle with was really under the radar. Reactive attachment disorder, PTSD and other ills that affect children who were traumatized by, if nothing else, being separated from their mothers, are becoming mainstream concerns, thanks to articles like this one from the Boston Globe.

In "Choices of the Heart," Patricia Wen tells the story of a family that almost relinquished their son when he was 15. Luckily, as a last resort, they found an attachment therapy center that, after months of intensive work, allowed him to heal -- and return to the family.

RAD Becoming Recognized

The horrible stories about the abuse of children with reactive attachment disorder in the foster and adoption system just keep coming.

Therefore, I'm especially happy to read this story from the UK of a woman who's had success in mothering RAD kids.

Sue Clifford began adopting traumatized children in 1991. She intuitively developed parenting styles that help them, in advance of the new understanding neuroscience has provided in the last ten years.

Adopting for Love

Ralph James Savarese's op-ed in yesterday's Los Angeles Times is so inspiring for its depiction of a parent's unyielding love for a child.

Savarese is the author of "Reasonable People: A Memoir of Autism and Adoption," coming out today from Other Press. The book tells the story of their son's rebirth after eight years in their care. The six-year-old they adopted had been diagnosed as autistic, abandoned by his mother and abused in foster care.

They had bonded with him when Savarese's wife, an autism expert, had attempted to help the mother. Their love for him was already too strong to let him slip away into a life of trauma.

He writes,

"Despite the stigma attached to "special-needs children," people do adopt these kids. And yet, many more Americans spend gobs of money on fertility treatments or travel to foreign countries to find their perfect little bundles. I'm haunted by something my son wrote after we taught him how to read and type on a computer: "I want you to be proud of me. I dream of that because in foster care I had no one." How many kids lie in bed at night and think something similar?"

His editorial is full of righteous anger at the callous way society looked at his son, and it's full of steady love. This should be a terrific feel-good book for all parents and a must-read for anyone who wants to have a child, biological or adopted, disabled or not.

Book Review: The Connected Child

Karyn Purvis, David Cross and Wendy Lyons Sunshine have written a handbook for parents of at-risk kids that's vitally needed. With the rise in international adoptions and adoptions of kids in foster care has come a mostly unacknowledged crisis. Unprepared and unsupported families are finding themselves unprepared for the task of parenting children with severe emotional problems.

The Connected Child helps parents put some of their therapeutic techniques into practice; more important, it helps them understand their kids in a new way.

Dr. Purvis is the director of Texas Christian University's Institute of Child Development; Dr. Cross is associate director of the institute and a TCU psychology professor. They treat kids with attachment and other behavioral disorders, and they run a summer camp for kids.

The book explains to parents how their assumptions of normal and acceptable behavior may be completely foreign to their children. Not being touched, not having enough to eat, not having toys or stimulation can create a worldview that's totally out of synch with the parents.

That's why setting rules for behavior or other cognitive approaches may not work with these kids. When parents understand that so-called bad behavior comes from fear or self-protection, they can find strategies that address the underlying fear and thereby change behavior.

For example, stealing or hoarding food is common among children from orphanages. They had no choices about when or what they could eat, and often didn't get enough to eat. Instead of demanding that the behavior stop, or that kids hew to mealtimes, the authors offer techniques to maintain a healthy, regular diet while increasing feelings of security about food.

For example, if a child asks for an energy bar a few minutes before mealtime, instead of saying, "No, we'll be eating in ten minutes," they advise giving her the bar and letting her choose whether to keep it in her pocket or by her plate to eat after dinner. Another option is letting the child keep a basket with healthy snacks in her room that she can eat whenever she wants.

Even sending a kid to her room for a time-out can hurt more than it helps, they write. If a child already feels cut off from the family, this isolation seems to reinforce that belief. Instead of dealing out consequences for misbehavior that may seem arbitrary and unrelated to the misdeed, Purvis, Cross and Sunshine illustrate how to help a child understand the real consequences of his behavior. For example, if a kid mistreats a dog, parents are advised to sit down with him and brainstorm the negative consequences of the behavior, such as, "If I hit the dog, it will run away from me." Next, they should make a list of positive consequences that might occur if the dog is treated kindly, such as, "It will like me."

They write,

"Adopted and foster children deserve deep compassion and respect for what they may have endured before they were welcomed into your home. Some of these little ones have survived ordeals that defy the imagination. … the difficult history of these children means that you, as a caretaker, have to work harder to understand and address their unique deficits and make a conscious effort to help them learn the skills they need at home with a caring family."

Parents need to respond to acting out, tantrums and other dysfunctional behavior with love and understanding. Over and over, the book helps parents understand the roots of misbehavior, so that they can respond with love instead of anger.

At-risk kids need to be told directly and simply what's expected of them, according to Purvis and Cross. Parents should identify specific behaviors or values they want to enable, and name them, for example, "asking with respect." If a child asks for something demandingly, the parent says, "Is that asking with respect? Can you ask me with respect?" Throughout, the book provides clear strategies and scripts for handling a wide variety of problems and behaviors.

Finally, The Connected Child includes a chapter called "Healing Yourself to Heal Your Child." Without judgment and with much compassion, the authors point out how much any child, and especially a traumatized child, needs to feel secure and loved by her parents. If a parent hasn't dealt with his or her own grief, anger or emotional dissociation, it will be difficult for that child to heal. If the child does begin to open up, it may actually make her parents uncomfortable.

They offer some advice for such parents, which tends to be on the cognitive side, such as reflecting on their own attachment styles and practicing identifying and articulating their own feelings. Of course, this isn't always so easy, and parents with attachment issues may benefit more from the same kinds of experiential therapy that kids get.

In fact, guiding a child with an attachment disorder toward healing could be exactly the kind of experience that could help a parent heal -- as long as it's done consciously and carefully. The Connected Child is a wonderful guide.

For background on the work of Dr. Purvis and Dr. Cross, see this article from the Texas Christian University magazine.

Interview: Dafna Lender, Theraplay Institute

Dafna Lender is training director and clinical coordinator for the Theraplay Institute, an organization that trains teachers, social workers and psychotherapists. Theraplay provides a structure for activities that help heal kids' attachment problems.

HUG: First, tell me how you got involved with Theraplay.

Lender: My involvement began when I was working in a foster care agency that had a residential component. Most kids had been adopted previously or been in a nuclear family, and their history of abuse, neglect, separation, loss and trauma had caused them to disrupt the place they had been in.

We found these kids were still unprepared after two years with us to go into a family. We were looking for some sort of method or therapy model that would help. I was sold from the beginning, and it was transformative for me, too. I felt I had hit on what I needed for the clients I was working with.

HUG: I've been hearing more in the news about reactive attachment disorder, and about failed adoptions. Is this problem increasing, or is there simply more awareness?

Lender: We have had a huge influx of parents who call us with these problems in the last ten or fifteen years, as societal problems get worse, and funding for social services diminishes -- and foreign adoptions become more common. There also is increased awareness of attachment issues. I definitely think it's a phenomenon that's increasing in size with not enough resources.

HUG: I've been distressed by some parents' accounts of adoptions that didn't work out. The parents seem not to understand how deeply messed up these kids are.

Lender: Parents do try very hard, and the lack of resources and support from the child welfare system or adopting agency can leave adoptive parents really depressed, resentful or despairing. They may feel like they're going crazy. An attachment therapist would help the parent put the child's behavior's into context so that the parent does not feel that they have gone crazy or are bad people. The attempt in the attachment community is to say it's not all the child's fault, but not the parents' fault either.

The child is projecting all this non-conscious trauma onto the parent. Most trauma that happens to kids is out of their awareness, because either it happened before they were verbal and therefore have no recollection of it, or they're defended against it, because it was such a horrible experience.

The only way for a parent or therapist to interact or give healing to these kids is to not to take it personally. That's a very difficult feat and requires a great deal of work on the parents' part and a great deal of support from a therapist. If parents sound callous, it could be because they have not received this help.

HUG: Do you buy the diagnosis of reactive attachment disorder, or RAD? There's no mention of this disorder on the Theraplay website.

Lender: There are a lot of problems with the diagnosis. There's a lot of overlap with other diagnoses, and no criteria that are discreet from others. Other people have talked clinically about attachment issues in terms of both severity and features that are more on a continuum, and that is more helpful clinically.

HUG: You work with both mother and father, if available. What about the idea that mother is primary regulator of brain and affect development in the first years?

Lender: That's definitely the case, but we don't work with kids during that period of time. Parents typically bring kids in toward the end of their second year, or before they start preschool. After the first year, the father is important typically -- although this is a stereotype -- in providing high levels of positive affect. This is important in being able to regulate high arousal, enjoyment, joy, interest and excitement. A child needs that just as much, so he doesn’t go berserk if he's waiting in line for the playground, for example. It also wards against depression and creates a great bond. So we love to focus on both parents.

HUG: There's an emphasis in Theraplay on certain special moments of connection that lead to change. Can you talk a little bit about this?

Lender: Those are called "now moments" or "moments of meeting" in the psychotherapy literature. It has to do with when two people are spontaneously sharing an idea, and they know that. It's an expansive moment, when we shared something that was meaningful. For example, when we're playing bubbles, and it pops right on the tip of the child's nose. There's a moment where he's startled, and then thinks it's funny, and I laugh too, and it's amplified. It's not something planned by me, it has to just happen.

HUG: Theraplay was developed for the Head Start program. Is there a change in the client base in the past few years?

Lender: In the last few years, there's been an increase in the severity of the abuse and neglect, the number of placements, and the rising awareness of the effects of drugs and alcohol in utero. On a parallel stream, there's also more and more focus on autism and early diagnosis, and we're known for that, as well.

Theraplay is a registered service mark of The Theraplay Institute, 3330 Old Glenview Rd, Wilmette, IL, www.theraplay.org

Meth, RAD and Attachment Therapy

Kicking off the second day of Cal State Chico's Children in Trauma conference, Butte County District Attorney Mike Ramsey talked about the county's Drug Endangered Children Program.

Ramsey said that narcotics police would make drug busts, clear out the drugs, arrest the adults and push the crying kids into the arms of the first available adult -- who might themselves be drug addicts. There may be three generations of meth users in a family.

He said, "One issue is the disconnect of these children that have no parenting, children that are left alone and passed from caretaker to caretaker. Absolutely flat affect in children taken from these homes. Most of us coming from "normal" homes would expect that when heavily armed narcotics agents break down the door, the children would be very frightened about being taken from their parents. But all it takes is for a CPS worker to come in and say, "Hi kids, we're going to McDonalds," and those children leave the parents in a flat second because they haven't bonded with those parents."

In response, main presenter Allan Schore, author of "Affect Regulation and the Repair of the Self," reminded the audience, "We now know that even in the earliest events, infants are extremely aware of events and of their strongest attachments."

He said that while a child might have flat affect on the surface, there are likely rage and fear beneath the surface.

His presentation today focuses on how and why therapy works. He said, "Therapy is not a talking cure, it's a communication cure." That is, the therapist and patient must connect in the right hemisphere, the source of feeling.

Quick Note from Chico Children in Trauma Conference

The first day of Dr. Allan Schore's seminar on Children in Trauma is almost over. It's inspiring to have the current theories of attachment and childhood brain development laid out so clearly and substantively. Schore is including many references to the supporting scientific literature. I have reams of notes and an immense amount to process -- as does everyone else.

The audience is a mix of social workers, counselors, child advocates, attorneys and others in the legal and social welfare systems.

It's daunting to hear just how critical nurturing is to an infant, and what deep damage can be done. 

In Tronick's "still-face experimental paradigm of traumatic abuse, a mother is asked to briefly show a fearful expression and then to let her face go completely still. Both mother and infant get stressed when she is asked to make the dead face. Shore emphasized this: "Not only when the mother makes a fear face, but also when she makes a dead face, it's extremely stressful to the child."

In fact, in the tests, the baby typically goes into a defensive strategy of massive disengagement -- the same you see in babies who have been extremely neglected, for example, in "Spitz hospitalism" and Roumanian orphans. But this happens so quickly. Schore said, "We don't need to separate mother and baby. The defensive strategy of massive disengagement happens in just 20 seconds."

But there is plenty of hope. One quick takeaway is that, just as in a marriage, a child can handle a fair amount of stress as long as the mother or caregiver reconnects with the child afterward.

Schore says that for this reason, neglect is much more damaging than abuse.