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,

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.

When a Kid Is a Lemon

In some countries, there may be whole generations in which the majority of people suffer from the inability to bond. Orphanages are full of traumatized kids who have never learned to love, kids who are so angry and afraid that they're unable to survive in a family.

Many of these kids, suffering from reactive attachment disorder, or RAD, could be healed, but only at great cost and with an extreme commitment of time and resources from their adoptive parents. Neurofeedback can help develop and change brain structures, while cognitive therapy, psychotherapy and unremitting attention and love can train the brain to respond to physical and emotional intimacy with soothing, healing oxytocin instead of the neurochemicals of fear and anger. Some day, I think, exogenous oxytocin will be administered as part of the therapy for RAD.

But these  therapies aren't accepted as treatments for RAD, nor is there money available from social services.

Instead, too many kids will suffer the fate of a 12-year-old boy adopted from the Ukraine. According to a story by Mary Divine of the St. Paul Pioneer Press,

The troubled boy was adopted when he was 7 and brought to Minnesota from the other side of the world.

Four years later, his parents were saying they had given up trying to deal with the disturbing, sometimes violent, behavior his mother described: He broke his little sister's ankles. He killed animals. He ran away.

They tried and failed to have another family adopt him. Then they returned with him to Ukraine, where he was born. They left him at a psychiatric hospital. They said they would be back. And they never returned.

The boy was returned to Minnesota, where social workers are trying to figure out how to help him.

In general, parents who adopt do so "with their best hopes for their family and what can happen, and it's devastating when things don't turn out as they had imagined," said Tamara Kincaid, a social-services supervisor for the county. "Either the child has needs that the parents just don't have the capacity to meet, or the parents just aren't able to follow through with it."

But, she said: "We don't have lemon laws on kids. There isn't a return policy."

What should happen to these damaged kids? Should we continue to warehouse them in institutions, drugging them into a stupor so they don't harm each other or themselves? Should we ship them off to war when they're old enough?

What will happen when this little boy is put out on the street at 18?

The Adoption Dilemma

This very honest account of a couple's adoption decisions is heart-breaking as well as inspiring. Rapid City (Iowa) Journal editor Mike LeFort and his wife adopted two children from a Russian orphanage, and LeFort doesn't pull any punches when he describes how they chose between two little girls.

The LeForts had planned to adopt a two-year-old girl and a one-year-old boy, and he describes the odd duality of being intelectually prepared for adoption, and then having to make the physical and emotional connection.

Surreal wouldn’t describe that Tuesday morning in a Siberian baby home, the morning in which two Russian caregivers brought out two little strangers and walked them over to us and said, pointing at my wife and I:

“Mama. Papa.”

They bonded easily with the little boy, but not with the girl.

She kept us at a distance in our visits thus far, preferring to play on the other side of the room or sit on a rocking horse and stare forward. She was apprehensive, didn’t want to be touched, and we weren’t so sure she was ready for us ... or needed us.

We knew that it was unfair to judge a 2-year-old on just a couple visits; the children are put into a very unfamiliar environment. Their surrogate parents — the group caregivers — leave them with two total strangers who speak an unknown language and are examining their every move, photographing, videotaping ...

No, it’s not fair to the child to expect them to “perform” to our liking, but parents are expected to make a decision in a matter of hours, and it’s a lifelong decision, and it must feel right.

The LeForts decided not to adopt her. The agency located another little girl who was at risk for fetal alcohol syndrome, but who was also "a delightful, intelligent, engaged strawberry blonde-haired bundle of curiosity." This little girl became their new daughter and the boy's new sister.

LeFort is clear that these decisions had to be made with too little information, and he knows that either or both of these children may be at risk for reactive attachment disorder or other problems.

Putting this in the frame of the oxytocin response and brain development, if, as is likely, either of these children did not receive cuddling, gazing and mirroring behavior as they nursed,  their brains may not release the oxytocin pulses that normally occur when we're physically close to another person. Without these oxytocin pulses, people don't feel bonded to another, they don't feel trust, they don't feel safe.

LeFort's moving story also shows how the way we respond to our earliest experiences can determine the course of our lives.

Of course, that first little girl, aloof and apprehensive, needed them. But the way she had dealt with not having a mother was to try to not need one. She needed them desperately.

The way these orphanage visits are handled is similar to the "strange situation" test that psychologists use to determine a child's attachment style, that is, what she's learned to expect from other people. This little girl became what they call "avoidant." She learned that other people would hurt her, either actively or by rejecting her.

I don't blame the LeForts. Parenting is above all an emotional task. They were right to make the choice they did, and he was brave to write so openly about the experience. 

They could only adopt two kids  -- and there will always be a withdrawn and desperate child left alone in the corner.

Jail for Child Killer

Jeannette Killpack, the woman who killed her four-year-old adopted daughter by forcing water down her throat, was sentenced to one to 15 years in jail.

The Killpacks claimed that this was a treatment recommended by a therapist treating Cassandra for reactive attachment disorder (RAD). At other times, Jeannette bit Cassandra and choked her. When asked whether such actions could have made it difficult for Cassandra to bond with Jeannette, Richard Killpack said that hadn't occurred to him.

U.S. courts tend to treat children as property, returning abused kids to their parents at the slightest sign or remorse or rehabilitation. But Judge Claudia Laycock refused to sentence Killpack to home confinement so she could take care of her four other children. The Deseret News quotes Utah County Deputy Attorney Sherry RaganUtah County Deputy Attorney Sherry Ragan:

"I do not believe she is a good mother," she said. "I believe her children are better off without her at this point. . . . She's a very dangerous person who is a threat to children."

Early Neglect Lowers Oxytocin Response

Psychologists at the University of Wisconsin at Madison published a study today showing that early neglect or lack of nurturing weakens kids' oxytocin response, as well as the levels of vasopressin, the related peptide that seems to influence male bonding and fathering, as well as social memory. According to the University,

"The new finding demonstrates for the first time that severe neglect and social isolation can directly affect a young child's neurobiology in ways that potentially influence emotional behaviors. "

I thought that brain scanning studies already had shown this. At any rate, researchers led by Alison Wismer Fries and Toni Ziegler tested the urine of 18 four-year-old adopted kids for base levels of oxytocin and vasopressin. They noticed that these kids had lower than normal levels of vasopressin. These children had lived in Roumanian or Russian orphanages before being adopted.

Next, the kids sat on the laps of either their mothers or an unfamiliar woman for a half hour, playing a game that involved sweetly intimate activities such as whispering, tickling and patting.

While such cuddling resulted in a rise in oxytocin levels in children who had been reared by biological parents, the kids who had been deprived of early nurturing showed no increase in oxytocin.

The study shows how the oxytocin response can be stunted.

Speaking of adopted children, the study's lead author, Seth Pollack, told  Newsday,

""Many parents describe these kids as overly anxious," Pollak said. "One of the explanations may be that the comfort system isn't kicking in."

Newsday writer Jamie Talan says, a bit naively,

"The finding, published Monday in the Proceedings of the National Academy of Sciences, suggests that early experience can leave a biochemical mark and that, in turn, can shape lifetime experience."

I think it's a lot closer to fact than to suggestion.

A Dad's View of Adoption

Adoption - A Dad's View is a very honest description of what it's like to parent two kids with reactive attachment disorder.

His blog details how it felt to go through the adoption process, how they handle discipline, when things go wrong. About his daughter, who's in the fourth grade, "Synthezoid"  writes,

Even when she is showing affection, she can be aggressive. Her hugs feel more like a tackle sometimes. We’ve tried to show her the difference in “good hugs” and “bad hugs.”

Synthezoid sounds like he may not be getting the information and support he needs. In his most recent post, he writes,

I felt like my life could be better, then I felt guilty about having those feelings. Then I wondered what the hell I was even doing at this frivolous gathering when I had responsibilities at home. Then I wished all those responsibilities would just vanish and I could just go find a quiet place to sleep.

I hate these children of mine now. I need a vacation.

I can't really imagine how hard it is. It sounds like he might be doing that "manly" thing of trying to stuff down his feelings. And it's interesting that he calls himself Synthezoid. His feelings definitely come through as real.

RAD Epidemic in Russian Adoptions?

The problem of adopted kids who have damaged attachment mechanisms hit the mainstream press today with this article in USA Today. An expert that reporter Steve Freiss talked to says up to 80 percent of such kids may have problems.

"We say there are three groups of children: about 20% whom we call the 'resilient rascals' because they come over and thrive right away, about 60% who we call 'wounded warriors' because they have serious problems but they get better after the first year or so, and another 20% who are challenged children who may require lifelong help," says [Victor Groza, a social work professor at Case Western Reserve University in Cleveland].

While this article focuses on kids who come from Russian orphanages, what I've heard anecdotally is that this problem isn't limited to Russia or Eastern Europe; any child who has to spend time in an institution before finding a home may suffer.