How Adoption Alone Does Not Heal a Hurt Child
An adoptive mom’s exploration of the neurological impact
of trauma, neglect, and sensory deprivation
By Heidi Holman
Short Circuits: A Baby's Story – the bases of developmental trauma
One cold morning a beautiful, healthy baby girl, 3 days old, wakes up to find herself alone on a deserted street, hungry and cold. Her mother does not answer her cries, and in fact no one responds for hours. The baby, increasingly agitated and distressed, screams with primal urgency. Eventually a stranger happens by, picks up the crying baby and delivers her to the police station. Through several more intermediaries, the baby is eventually delivered to the local orphanage. Examined by a doctor and then wrapped in blankets and fed a bottle, she is deposited into a crib and left alone for much of the rest of the day. That night, no one comes to answer her frantic cries. More days go by, more cries unanswered. Care is administered on a rigid schedule, since the caregivers have so many babies to attend to, and there is minimal opportunity to be held, carried, or spoken to. Stimulation is limited to what the baby can see, hear and feel from her crib. Feedings are bottles of formula, propped for maximum efficiency, delivered through extra large holes in the nipple. Occasionally the baby’s mouth loses its place on the nipple and the entire contents of the bottle pours onto her body. When that happens she misses her feeding, and her wet clothes aren’t changed for another hour or more. Eventually the baby stops crying altogether because she has learned that crying rarely draws anyone to her. She is often lonely and scared, especially at night. The sounds of other babies crying and in distress cause her great anxiety, which she learns to tolerate by shutting down and withdrawing deeper inside herself in an attempt to protect herself from the constant stressors in her environment. One day many months later, the baby is bundled up and brought by bus to a city several hours away. She is handed to a stranger with just the clothes on her back and one bottle of prepared formula. Otherwise, everything of her old life has vanished in an instant. The stranger brings her to a hotel across town, where she is changed into new, peculiar smelling clothes. The stranger shakes a brightly colored rattle in her face. The baby’s environment has gone from one of minimal stimulation to one of hyper stimulation; new sounds, new smells, new sights, new sensations, delivered in rapid fire sequence. The stranger tries to feed her a Cheerio, but the baby reflexively gags because she’s never had solid food in her mouth. The stranger tries to bathe her in the sink but the sensation is unfamiliar and terrifying. The stressed baby, overwhelmed, sinks deeper and deeper into a state of shock and withdrawal. And they lived happily ever after.
I adopted Sal when she was 13 months old. Malnourished and developmentally delayed, it was a long time before she caught up to her chronological peers. She received 18 months of Early Intervention services, a federally mandated and state funded program administered to children at risk for developmental delays in the US. She was stoic and independent. For the first couple of years she would not seek me out for comfort, even when she was hurt. Her first spontaneous hug at age 3 gave me a visceral shock. I understood for the first time that she had merely been tolerating my hugs until then.
I believed children to be resilient, and over time I saw evidence that Sal had overcome the deprivations of her first year in an orphanage. She grew physically strong and healthy, and began to meet all of the developmental milestones for her age. I also had my first adoption of big sister Jenny as a frame of reference. Jenny was happy and healthy, successful at school and socially. Surely with time and TLC, Sal would follow in her sister’s footsteps. The first tangible clue that this was wishful thinking on my part didn’t surface until Sal was 5 years old. Sal was a funny, spirited and joyful child. She was charismatic, laughed frequently, enjoyed playing with friends, and was something of a clown.) and had an exuberant magnetism. One day driving somewhere in the car Sal suddenly started crying convulsively. I thought at first she had been injured, the sobs were so urgent. I whirled around to ask her what was going on, and after a few hiccupping gulps she blurted out “I miss…..my bouncy seat!” The last word was swallowed by a wrenching wail erupting from deep in her gut. Speechless, I kept driving, trying to understand the disproportion between the stated source and the impact. Sal hadn’t played in a bouncy seat for several years. To my bewilderment, Sal began to have similar episodes multiple times a week, mysterious outbursts of some long forgotten thing. She would dissolve in gut-wrenching sobs for no apparent reason. They would occur at random moments. Each time she would attempt valiantly to name her grief, as she tried on one explanation after another. “I miss…….my ayis…my jingly toy…Grandma…my bottle…China…my crib.”
Around the same time she began to have explosive rages. Her emotional state was so heightened in these episodes that she seemed to be having an out-of-body experience. The rages were always triggered by being around children and this time Sal knew their cause. She was mad because she “hated the babies.”
When the Bonding Cycle is Broken
Attachment is the trusting bond that first develops between a mother and child, beginning in infancy. Healthy attachment is formed through repetition of the cycle of needs being expressed and then met. A baby is hungry so she cries. The mother hears the cries, and she immediately responds. The baby is fed while the mother actively works to soothe the baby’s agitated state. As the cycle is repeated and reinforced thousands of times, the baby learns to trust that her needs will be met and that the world is a safe and good place. If this cycle is not regularly completed, it can have devastating implications for the emotional health of the baby.
Having a primary emotional bond with an attuned caregiver who predictably meets a baby’s emotional needs is foundational for healthy psychic development and the ability to form healthy relationships with others. The ability to process and regulate one’s own emotional state effectively, to delay gratification, to problem solve, to have empathy for others, are all critical for a healthy and secure sense of self. These are skills that are developed through the formation of healthy attachment.
In early developmental stages, an agitated or hyper-aroused baby must be soothed by her primary caregiver in order to feel calm, safe and secure. The baby actually experiences her own emotional state as an extension of her caregiver. If her emotional needs are consistently met, over time the baby is able to take on some of this emotional regulation herself. Throughout early childhood, skills of self awareness and self regulation are reinforced. From there the child is able to begin to process the emotions of others, to develop a sense of empathy and to form healthy relationships beyond the primary one. These are lessons with clear and lifelong repercussions, negative if the bonding cycle is broken.
Some simple questions flow from this:
•Would adoptive parents recognize how a child grieves?
•What tools do parents need to cope with a child grieving for loss of the unknown?
•How do parents help a child develop resilience around loss while supporting the child’s right to feel loss?
I began to see that my intuitive methods in dealing with Sal’s outbursts and rages were not adequate. No amount of loving or reasoning or logical consequences or discipline had any impact on her difficult behaviors. I felt like I was spinning my wheels so I began to research, seeking out books and Internet sites devoted to adoption issues in post-institutionalized children, hoping to find some insight. Much of the available information on adoption issues focuses on attachment. But reading about attachment didn’t help me to fully understand Sal’s inexplicable out-of-body rages and grief or the times she would dissociate under stress and just freeze. She had few of the other red flags for attachment impairment; she was affectionate and loving to me and her sister, had learned to come to me for comfort, was often joyful and exuberant. She had come so far from the withdrawn, affectless and listless baby that I had brought home. Deep down, I questioned whether Sal had any attachment issues at all.
As an adoptive parent, I had some understanding of attachment theory. I knew that children who spend time in institutions, or who experience multiple ruptures in caregivers, have not had the opportunity to form healthy attachment to anyone. I understood that this was a process she would have to undergo with me, and I understood some basic strategies for promoting attachment. I understood that I needed to respond to Sal at 13 months as though she were a newborn. I understood that she needed to learn to rely on me to meet her needs. I understood the importance of promoting eye contact, skin contact, little forms of intimacy to which she was not accustomed. I understood that she might need to be carried on my body, to co-sleep, to feed from a bottle, for a prolonged period of time, long past the age when these habits are indulged in biological children. What I didn’t understand was that these strategies, time, and a mother’s love would not be enough.
What is Trauma?
It’s known that trauma occurs when an event elicits a real or perceived threat of danger, injury or death. Trauma triggers certain neurobiological responses, a primitive survival mechanism. The body experiences a fight, flight or freeze response to the threat. Stress hormones, mainly adrenaline and cortisol, flood the body and brain. The body is thrown into a state of hyper-arousal and hyper-vigilance; heartbeat races, muscles tense, breathing accelerates. An adult in this hyper-aroused state is unable to access higher order thinking, as the body is primed for an immediate response on a primitive level to the threat. Fight? Or flee? While these are effective neurobiological strategies for dealing with actual threat in the short term, they can be damaging to endure in the long term.
Prolonged exposure to trauma can permanently alter the biochemistry of the brain. Over time the amount of cortisol and adrenaline released in the body can cause a sensitization in the part of the brain associated with the stress response. The repeated triggering of this stress response can result in the child persisting in this state of fear long after the threat has passed. Symptoms can persist for years after the actual trauma in the form of hyperactivity, anxiety, sleep disturbances, impulsivity or emotional hypersensitivity, as well as episodes of reliving the trauma. Neglect, while not a single traumatic act, can be experienced by an infant as ongoing trauma. The neurobiological responses are similar. An abandoned newborn, completely dependent on her mother, experiences trauma; physical abandonment is literally a life or death threat to her.
An infant left alone physically and emotionally may live in a state of prolonged fear and hyper-arousal, causing the brain to be awash in large amounts of stress hormones. Unable to summon help, and unable to physically flee, an infant might respond by dissociating from her body, another primitive coping mechanism At this later stage of trauma, stress hormones used for coping with a single incident are burnt out Maladaptive brain function on this primitive level can also have profound implications for development of higher brain executive functions. Scientists report that in abused or deprived children the parts of the brain responsible for regulating emotion and memory are significantly smaller than in non-abused children. Many traumatized children develop symptoms that resemble ADD/ADHD, such as inattentiveness, aggression, and non-compliance.
In the end, I was not able to crack the mystery of Sal’s behaviors on my own. I made an appointment with an attachment therapist. The therapist spent one session interviewing me extensively about Sal, and another observing her directly in facilitated play. Her diagnosis was that Sal had Post Traumatic Stress Disorder, a condition that was interfering with her forming a secure attachment to me. Though the diagnosis was like a punch to my stomach, I felt a simultaneous sense of relief that there was an identifiable syndrome underlying Sal’s behaviors. There was the possibility of therapeutic intervention and healing. The diagnosis also joined several disconnected dots for me. Sal’s behaviors were related to an attachment problem, but could only be understood within the broader context of trauma.
With PTSD, a trigger can transport the afflicted person instantly to the neurobiological state of trauma and she can experience the trauma anew as though it is something happening in the present, even if it happened years ago. In this state, the higher functioning brain is disengaged. My trying to deal with Sal’s episodes by using logic, discipline, time outs, or worse, reacting with my own heightened emotional state, was ineffective and counterproductive.
Armed with this theoretical framework, we began to peel back the layers of Sal’s behaviors. I began to understand what her triggers were, and I was astonished to discover how much of her infant experience had been stored in her brain. I had always believed that pre-verbal memory was not accessible. And yet, it became clear that Sal’s pre-verbal experiences were being accessed when the PTSD was flaring up. Sal’s rages were manifestations of the extreme stress and threat she had felt as an infant in her orphanage, neglected and frightened, unable to summon help.
One of her triggers was children crying or yelling; exposure to this would instantly transport her to a hyper-aroused trauma state. Sharing or shedding belongings was another trigger; long past the age when most kids learn to share, Sal was unable to do so. On a fundamental level, she was unable to share because she perceived other children as a threat. She had no internalized sense that the world was a good, bountiful and safe place. Her primitive brain had learned that her needs would not be met, and she responded in a primitive way—with fear and anger. Once I began approaching her behaviors with this framework, her relief was palpable.
Once I was able to react to her outbursts calmly and provide the right words, give her a context for these large, scary feelings and help her begin to process them, she began to respond. It was counterintuitive because it involved going right to the source of her pain: her first year in the orphanage, the loneliness, the fear, the anger, the hurt she had endured as a helpless baby. As her mother, my first impulse had been to protect her from that pain by avoiding it. What I learned from our therapy was that the only way through it was to confront it dead on.
My first opportunity to confront her pain came one night at bath time. I had drawn a bubble bath, a treat for Sal and Jenny. But almost immediately I heard Jenny loudly complaining that Sal had pulled all of the bubbles to her side of the tub. Exasperated, my first impulse was to tell Sal that she needed to share with her sister. But I stopped myself. Instead, I knelt down on the bath mat, leaned into Sal and wrapped my arms around her. “I bet this reminds you of when you were a baby,” I said. Sal started sobbing quietly. “Does this make you think of a time when you were little and didn’t get what you needed?” I asked softly into her hair. Sal continued sobbing, nodding her head. “Sweetie that was terrible what happened to you. No baby should have to go through that. But you’re with me now and I will always give you what you need. You see all these bubbles in the tub? I have more. See that bottle on the shelf? It’s only half gone. And when it’s empty, I’ll go to the store and buy another one. You don’t have to worry anymore.”
Sal snuffled a bit, then started pushing half of the bubbles to Jenny’s side of the tub. I was stunned. How could it be this easy? What power there was in this simple acknowledgment of a piece of her pain. For the first time, I was able to talk her down from her hyper-aroused state. For the first time I felt like I held the key to an impenetrable door. I began to see how inextricably linked trauma and attachment are. I saw how PTSD was preventing Sal from handing over the last modicum of control necessary to trust that her needs would absolutely be met. On some primitive level, she felt that she needed to be vigilant and protect herself, whether by hoarding the bubbles, dissociating from her body, or raging at the perceived threat of another child.
The Pervasiveness of Trauma
It is known that the newborn infant brain is quite immature and plastic. Research has shown that over time, the brain develops sequentially, from the bottom up, starting with the brain stem and moving up to the cerebral cortex. Primitive functions develop first and lay the groundwork for more complex functions like emotional regulation and higher order thinking. Brain growth and development are governed by experience. Experience also dictates neural wiring.
Research shows that the central nervous system is a self-organizing and dynamic system that develops in direct response to life experience. Through repeated exposure and processing of stimuli, neural connections are built and the brain learns to organize and integrate sensory information efficiently. Gathering and processing sensory information is the normal developmental task of the infant. This information is brought in through all of her senses through interaction with her environment. Seeing, hearing, tasting, touching, development of muscle tone and balance are some of the interactive experiences that build neural connections critical for development and for moving on to higher levels of functioning.
Most babies first experience their world from the safe haven and safe arms of a committed carer- their mother. Many adopted babies and children may have lapses in this process because they may have not had opportunity to interact in a sensory rich environment. While they may appear to “catch up” developmentally once they’re adopted into loving homes, in many cases critical gaps in neural pathways will persist. Much like trying to build a house on a wobbly foundation, moving forward developmentally without revisiting the site of the sensory processing gap often results in a sensory processing or integration dysfunction. These kinds of dysfunctions can be extremely subtle and hard to detect for someone not trained to recognize them. Young children learn effective ways to compensate for sensory processing weakness. Unless the source of the dysfunction is treated, experts believe that it’s likely to surface as a learning or behavior issue around the time the child enters school.
Sensory integration dysfunctions often result in a child having difficulties organizing and interpreting information, making it very difficult for the child to keep up with the challenges of elementary school. The child works so hard to just make it through the day that learning, remembering, organizing and planning ahead are much more difficult than for the child who is integrating typically. Difficulties can emerge as auditory or visual processing disorders, or they might emerge as hyperactivity or difficulty focusing. Sensory processing disordered children can easily be misdiagnosed as ADD/ADHD because the symptoms are so similar. Sensory issues can also show up as behavior issues; inefficient or disorganized sensory integration can affect emotional equilibrium as the child struggles with the higher levels of functioning and more sophisticated learning that are the normal expectations of elementary school students.
If it weren’t for the suggestion from our attachment therapist that I might want to have Sal evaluated for sensory processing issues, I would never have thought to pursue it. But once I started researching sensory processing issues, I realized the signs were there. Among the red flags was her love of spinning and swinging. She loved tire swings, and could spin endlessly and never get dizzy. She was very active, hyperactive even, moving during every waking minute. Yet there were a couple of peculiar gaps in her fearless, high-energy antics. She showed occasional clumsiness. She was reluctant to get on a bike, even with training wheels. And she was tentative on the monkey bars, unable to master the hand over hand technique that other kids picked up easily. My reading suggested that these were clues of a dysfunction in her vestibular system, which regulates balance and the body’s relationship to gravity.
Many of Sal’s activities were attempts to stimulate that system. Her difficulty with the monkey bars betrayed poor bilateral coordination, a skill experts say ends up having profound implications for learning how to read. Sal was late to develop hand dominance, and her writing and drawing skills lagged behind her peers. Though she showed a solid understanding of phonics and letter recognition, she seemed to have difficulty writing letters.
Her drawings were unsophisticated, demonstrating little understanding of spatial concepts. All were indications of difficulty in organizing visual information. Though she was very verbal, there were times when she seemed to speak in startling non sequiturs, blurting out a narrative that I couldn’t easily follow.
I came to see that this belied a disorganization of thought and difficulty sequencing events. I sought out an Occupational Therapist trained in sensory issues. An evaluation revealed that Sal indeed had Sensory Processing Dysfunction By then Sal had been home five years and the signs had been missed by me, by her teachers, by her pediatrician, and by all of her Early Intervention therapists. The treatment for SPD is a set of targeted activities customized by the Occupational Therapist.
Sal was offered treatment which effected a comprehensive overhaul of her central nervous system, designed to stimulate neural connections and systems that went awry or never optimally developed. This kind of repair is possible because of the amazing plasticity of the brain and central nervous system. Activities targeted the vestibular system, proprioception, muscle tone, core strength, tactile sense, auditory sense, and visual sense. Over the course of several months we attended weekly sessions with the OT, and still incorporate many of the therapeutic activities as part of a home curriculum. Sal’s muscle tone and core strength improved, which in turn helped her sense of coordination and balance.
She worked hard and mastered bilateral movements such as swinging on the monkey bars. Her ability to organize the visual world improved, which helped with residual clumsiness as well as writing, drawing, and pattern recognition. But there were also improvements in other areas. I didn’t anticipate that her ability to regulate herself emotionally would improve or that her anxiety would abate. It is clear that it is helping her brain work more efficiently, which in turn is helping her reach higher levels of functioning. More significantly, doing the foundational work of filling in the gaps in her neural circuitry is also tangibly enhancing her ability to recover from the trauma and attachment disorders. Therapies that I had thought of as unrelated to each other were actually working in support of each other. It was a light bulb moment.
Parenting Pain and Insight
It is painful for me as an adoptive parent that I wasn’t there for my daughter when she was at her most vulnerable. I wanted to believe that her needs were consistently met in that first year in the institution. One of the first steps toward healing her has been to acknowledge that this image of her care is a fantasy. I also needed to understand that my love and best intentions alone were not enough to overcome the effects from that first year. It was an epiphany that her issues do not exist in isolation from one another; her insecure attachment is linked to both her PTSD and to her SPD. They are intertwined like an intricate Gordian knot, as tangled as her neurological circuitry itself. Understanding that and approaching her issues as a spectrum, with a holistic framework in mind, I believe has been key to her good progress. But more fundamentally, it took attunement to my daughter and a willingness to view her behaviors in a context and understand what I was seeing. Many well intentioned friends assured me that Sal's emotional outbursts were developmentally normal. It took some extra sensitivity, and trusting my gut, to see that something was indeed amiss. Initially, seeking out therapy was crushing; the last thing I wanted was for Sal to be slapped with a scary sounding acronym. But after the blow of that first diagnosis, I quickly learned to look past the labels and see that they don’t define who my daughter is.
Sal is not a pathology or an aberration. Her neurobiological and psychological responses to her experiences were completely normal; it was the circumstances that were extraordinary. Extraordinary, and yet typical for institutionalized children. I don’t believe that Sal is an isolated case. How many others are out there similarly affected? Why is it that some children fare better than others in the same context? How is it that some are able to get enough of what they need in sub-optimum environments? Of course, there is the unquantifiable element of resilience. How does resilience intersect with experience to jump start, or short circuit, brain development?
In my own personal study of 2 children, I have one who sails through life and one who struggles. Tellingly, the one who sails never spent a day in an institution, but lived with an exceptional foster family from 3 days old until she was handed to me at 9 months old. Her foster mother revealed to me that Jenny was beloved, held and spoken to almost constantly. I was grateful at the time, without fully comprehending the enormity of the gift she had given Jenny: the gift of an optimum beginning, nurture, love and sensory rich, the gift to develop her potential without struggle of impediment. Though this should be every child’s birthright, Sal was given no such gift. But somewhat paradoxically, she has bestowed unexpected gifts upon me. It’s easy to love the child who sails and excels, but for the child who struggles the depth and quality of love ends up being breathtaking.
Sal has stretched me the furthest and taught me the most. She has taught me about bravery and perseverance, strength, grace and humility. When I look at her I see the courage of a fighter and the heart of a hero. With only a small child’s understanding of the therapeutic paths we pursue, she intuitively embraces her therapy with enthusiasm. In this simple and affirming act of trust, I see someone who works hard every day to fully integrate the experiences of her first year. While experience perhaps isn’t destiny, it has molded who she is today. With full acceptance of that, I am working hard to help her become who she will be tomorrow.
© 2007, Heidi Holman
Heidi Holman is an adoptive mom, writer and filmmaker. She lives in San Francisco with her 2 daughters.