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TWO DECADES OF PRACTICE AND RESEARCH IN INFANT MENTAL HEALTH: WHAT HAVE WE LEARNED? a keynote address at the 20th Annual Conference of the MAINE ASSOCIATION FOR INFANT MENTAL HEALTH

Authors:
  • The Infant-Parent Institute
THE MIND OF THE BABY 1988-2008:
TWO DECADES OF ADVANCES IN INFANT MENTAL HEALTH RESEARCH
Michael Trout, Director
The Infant-Parent Institute, Inc.
Champaign, Illinois - www.infant-parent.com
Given the astounding revelations about the capacities of the human infant and the
nature of human attachments that issued forth in the 20 years before 1988, it would
have been difficult to imagine, at the time, that the next two decades would be even
more exhilarating, and revealing. But that is exactly what happened.
We would never have expected, in 1988, to read about attachment in the mainstream
media, much less would we expect a proposal like that made by David Brooks in an
op-ed piece in The New York Times, of all places:
If I had $38 billion, I would focus it on the crucial node where attachment
skills are formed: the parental relationship during the first few years of life. I’d
invest much of it with organizations, like Circle of Security, that help at-risk
mothers and fathers develop secure bonds with their own infants, instead of just
replicating the behaviors of their own parents. I’d focus on the real resource
crisis that afflicts the country. It’s not the oil shortage. It’s the oxytocin
shortage (Brooks, 2006).
Who could have known, in the 1980’s, that the invention of the MRI by my
neighbor, Novel Prize winner Paul Lauterbur, would have opened the door to
understanding the geography of the brain, and the physiology of thought and
movement and affect, and would have allowed us to actually watch these things
happen, in real time?
Who would have predicted that the genome project–which many saw as the final
death knell to the nature-nurture debate, with nature coming out as the winner,
would have brought about a quite different result: that, just as the identical-twins-
reared-apart research had suggested, years earlier, there really is no debate? It’s
over. And neither side won. It was always a joint project. Indeed, neither genes nor
experience are much good, without the other.
Who would have thought that the political climate of Eastern Europe would have
created a cataclysmic in vivo experiment in infant/toddler development in the 80's,
much less that the information about this experiment would quickly reach our
shores, because we adopted those kids, by the tens of thousands? And we suddenly
had, right in our living rooms, examples of precisely what had happened to Harlow’s
monkeys four decades earlier. We saw autism and attachment disorders co-existing,
and we quickly learned about the transactional nature of disordered attachments as
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we saw families go down under the rage and hurt of these little children who, now
offered what they never had, rejected it.
Who would have predicted that babies would increasingly find their voices, much
less that we would have to start listening to them tell us that surgeries without
anesthesia hurt, that newborn boys notice when the ends of their penises are
assaulted, that newborns of all persuasions are watching us when we move them to
new mothers?
In 1988, few of us had heard of evolutionary psychology, much less ecological
psychology–fields that would give us startling, but common-sense, explanations for
much human behavior on the grounds of its adapatability, and would finally declare
the end of the mind-body split. Descartes’ error would be revealed.
In these twenty years, fathers emerged as real caregivers to be reckoned with, and
we started to acknowledge that they experience pregnancy, too. Middle school girls
started beating up on each other. Four-year-olds started getting themselves thrown
out of preschool in unprecedented numbers. The frequency rates for identification
of autism spectrum disorders blew the roof off, parents challenged us about whether
government-mandated vaccines were causing it, and we learned some remarkable
new ways to treat certain of the children, especially on the Asperger’s end of the
spectrum. We began to acknowledge the capacities of single parents and gay
parents to adopt children, while we made little headway in acknowledging the rights
of adoptees to know their birthparents. In many states, we gave the right to young
girls who did not want their babies to drop them off somewhere, anonymously,
preserving the girls’ rights to go on with their lives but violating the babies’ rights to
ever know where they came from.
Cesarean rates had peaked in 1988–having grown by 500% since 1970, from 4.5%
to 24.7% (Leeman, L. and Leeman, R., 2003). After a few years of decline, in the
1990's, they headed up again, and we are fast approaching a rate of one in three
deliveries in America by cesarean section. American parents, birth plans in hand,
and delirious with the results when they were treated as real collaborators in birth
in the 1980's, have moved in another direction, since: Let me schedule it, and make
it not hurt.
In these years honorable folk have continued slugging away in the trenches, making
home visits, attending births, observing in childcare centers and in hospital NICU’s
and pediatric wings, consulting on foster care and adoption issues, testifying on
behalf of the best interests of young children, and trying to find even better ways to
listen to–and to be with–families.
I would like to report to you on the implications of some of these advances for
program and public policy, for practice and for further research, while focusing on
three areas of special interest: memory, genetics, and the meaning of adaptation.
I. RESEARCH INTO THE NATURE OF MEMORY, THE GEOGRAPHY OF
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MEMORY AND THE DEFINITION OF MEMORY.
In retrospect, it is embarrassing to see how short-sighted and unscientific we were,
during the 70's and early 80's, in our exploration of memory in early life. The
evidence has mounted that virtually no life experiences are cast aside (Perry, et al,
1995; Schore, 2002). One of the reasons we didn’t catch on, before, was that we had
trouble thinking beyond what we knew: adult, traditional left frontal cortex models
for investigating memory in babies and very young children. We failed to notice
that there are actually many ways to remember, many ways to store, many ways to
retrieve. When we thought of memory as a principally cognitive process, and one
dependent on language for proper retrieval, we saw that babies probably didn’t
qualify. Babies didn’t do much talking, and their myelination was insufficient to
allow the sort of cognition we believed was needed; therefore, they must not be
remembering.
We were a little slow to take note that pre-verbal experiences were unlikely to be
stored verbally. In other words, a three-year-old (or a grownup, for that matter)
would be unlikely to recall something that happened at three months of age, or even
in utero—both times when the baby was a little short on words—by telling us about
it. Not until we began to expand our notions about what storage or retrieval might
look like if done non-verbally did it dawn on us that an older child who tugs
constantly on his collar, or an adult who hates turtlenecks, might actually be
showing us that he remembers the cord wrapped around his neck during birth,
creating a temporary but terrifying anoxia. Could the nine-year-old adoptee be
telling us that she remembers something–even that she is looking for something, out
there, somewhere–when she stands by the window, day after day, staring out? Is the
eight-month-old who jumps at every sound, or the three-year-old who rushes to his
mother’s side whenever he thinks she is in danger, telling us that he remembers the
domestic violence that both of them experienced while he was still inside her?
Daniel Siegel suggests a particularly stunning model for understanding memory,
and its function in development:
Memory can be seen as the way the mind encodes elements of experience into
various forms of representation. As a child develops, the mind begins to create a
sense of continuity across time, linking past experiences with present
perceptions and anticipations of the future. Within these representational
processes, generalizations of mental models of the self, and the self with others,
are created; these form an essential scaffold in which the growing mind
interacts with the world (Siegel, 1999, p. 5).
Or, as Nobel prize-winning molecular biologist Eric Kandel puts it: “It is, of course,
memory that weaves one’s life into a coherent whole” (Kandel, 2006, p. 372).
But what are the indicators, in the here and now, that a child is remembering—or,
for that matter, that an adult is remembering something in early childhood?
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We have come to see that children demonstrate their own memories through their
behavior. Theodore Gaensbauer, Professor of Psychiatry at the University of
Colorado Health Sciences Center, reports distress, hyperarousal, behavioral
disorganization, and avoidance in young children who are later exposed to an
experience reminiscent of an earlier trauma (Gaensbauer, 2004). And the purpose?
The complexity of what young children are doing with these traumatic
representations is most impressive....with the resources available to them they
are, in common with all trauma victims, ‘telling their story’ in order to master
the overwhelming affects, develop a coherent narrative, and ultimately
integrate the experience (Gaensbauer, 2004, p. 30).
This way babies and young children have of “telling their story” is an important
component of survival, and of integrating experience. As Dr. Kandel puts it:
“...learning is conserved through evolution because it is essential for survival”
(Kandel, 2006, p. 186).
It is adaptive to hang onto crucial information that might be needed, later, for
survival (Perry, et al, 1995). When Anna’s dad put his penis in her mouth over and
over, during her second year of life, evolution demanded that she put those
experiences into storage. Armed with these memories, she could develop a strategy
for surviving the overwhelming affects. Language development stopped; she
refused to speak. In these acts of resistance, she took control of that orifice. She
could just as easily have become a voracious eater, or stopped eating altogether, or
chattered incessantly; it really doesn’t matter. The point is that she attended to what
was happening, and she worked out a plan. That’s what successful organisms do,
and they can’t do it if they don’t “learn” the experience, if they don’t remember
what they’re trying to defend against.
Beyond such direct observation of thinking, feeling and reacting going on in the
brain, we can now see more clearly what psychoanalysis suggested long ago: that
memory plays out in behavior. It is up to us to watch carefully enough to catch it,
and to support a particular child or parent in gathering it in and using it for growth.
Are we ready?
Wanda–a mid-40's mom with an advanced degree in health care and a tremendous
fear that her baby would choke to death, in spite of all medical reassurances that her
baby was fine–emailed me one night, with a profound question. It is the same
question I am posing to you right now. She inquired about whether she should trust
the startling body memories that were clearly roiling up in her, of her own abuse
when she was the age of her baby:
If there is no voice
no sight
no sound
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no way to
move the hands–
Does that mean
there is nothing
important to be said?
She was asking, in other words: If there were no reliable witnesses, except me, did it
actually happen?
And then the zinger: “So, here is a thought, Michael. If I have to translate an event
to you where I couldn’t see, hear speak, or move–what language do I use? How will
you understand? Do you speak that language?”
Indeed, do we?
These discoveries and new theoretical constructs about memory may be highly
inconvenient. They suggest a re-examination of social policy is in order, at least in
the areas of newborn adoption, newborn surgery, child welfare, and attitudes and
practices about birth, itself. They allow us to imagine that an older child or adult
who claims to have no memory of early life may actually have way more to offer in
this area than we ever imagined, once we get the retrieval questions resolved.
If the adoptee remembers his birth mother–even worse, if he remembers how
frustrated and depressed she felt because he was inside her in the first place–what
will this mean for our child welfare planning, or for our acknowledgment of his
right to someday find her?
Are we prepared to honor the behavioral manifestations of early memory in clinical
practice? When Christian–born to an alcoholic mother who was regularly beaten
by her boyfriend during the pregnancy–is born with that wide-eyed look that we
used to fancy meant he was alert, but which we now suspect may signal adaptive
hypervigilance, will we respect his cues about what he “saw” in utero—and what he
“learned” about the meaning of what he saw, for his own survival? Will we “hear”
him tell about his intrauterine relationship with his birth mother when–during a
conversation between his adoptive mom and the home visitor, when he is age five–he
crawls over to the adoptive mom on all fours, pushes his head between her legs and
into her crotch as she sits on a foot stool, and begins to rock back and forth, saying,
“Get away. Get away from me!”?
II. DEVELOPMENTS IN OUR UNDERSTANDING OF WHAT IT MEANS TO
“ADAPT”, AND TO BE “RESILIENT”
We pretty badly misunderstood such developmental concepts as “adaptation” and
“resilience” (Perry, et al, 1995), perhaps because it fit our paradigms–or maybe our
fantasies–better if we kept it very simple: Kids were tough. They would get over
things.
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But we have come to see that resilience has nothing to do with being tough, or being
unaffected by experience. And now we know that children are often being adaptive
when they engage in certain behaviors that are also disruptive, and pretty crazy-
looking.
We have come to see that the behavior of young children often makes sense. This
new way of imagining the meaningfulness, the adaptive sensibleness, of behavior can
lead clinicians to entirely new strategies for figuring out why a toddler rejects foster
mothers, or a grade-school child hits people, or a middle-school child cannot
concentrate, or an adolescent lapses into depression each spring, or an adult finds it
impossible to trust.
It’s superficially encouraging to just proclaim that kids are tough, resilient. And
they absolutely are–but not in the way we thought. We all have stories about kids
who have risen far above their circumstances, to achieve successes few thought
possible. But we must not misunderstand what happened in those cases; we must
not misunderstand “resilience”.
So what constitutes resilience, if not unflappability? Research seems to suggest that
there are certain children whose drive to survive is so strong that they invent new
adaptive strategies over and over. So, is it resilience that causes a 3-year-old to
watch her mommy kill her baby brother by bashing his head on the wooden arm of
the couch (and then blame her for it, when the police come), and then to withdraw
from the foster mom with whom she is placed, then later began to ride her tricycle
into the street several times a day for the first six months of placement? But how
can we understand these behaviors as adaptive, much less as evidence of resilience?
It is easy to see (if we are capable of looking at the world from the perspective of the
child) why it would be maladaptive to yield to her foster mom’s affection, thus
risking vulnerability and even attachment, after being treated so horribly by her
birthmother. But it cannot end there, since closeness is, in addition to being
dangerous, also an essential element in feeling protected from new dangers. It is, in
other words, what she does not want, but does need, almost more than anything. So
how could she get closeness without taking too many chances? How could she get
closeness without admitting she wanted it, without admitting her vulnerability?
The new science of mind suggests that the resilient child pushes further than most,
develops strategies, until her needs–at least as she experiences them at the time–get
met. And now she has figured out just how to do it: she will ride her trike into the
street over and over, stimulating her amazingly intuitive foster mother to run after
her over and over and give her a good talking to each and every time about how no
precious little girl of hers is going to get hurt around this house. And slowly—so
slowly that foster mom may need some special encouragement to keep up her
brilliant treatment plan—the little girl’s brain begins to shift: “Maybe I could be
looked after. Maybe children don’t always get hurt. Maybe I’m worth chasing.
Maybe I could trust.”
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These capabilities of the human mind may seem to send us in maladaptive or
nonsensical directions, behaviorally, as when the child of an alcoholic–who spends
her early years trying to learn how to control her parent’s drinking (because her
survival depends on it), and imagining that she actually can—grows up to be a
controlling person, or grows up dissatisfied with relationships in which she is not
called upon to “fix” something. But this largely right-brain activity means to do
what is necessary, to cleave to what is familiar, to reduce anxiety by whatever means
are available. According to the new paradigm, we do not necessarily become better
when we adapt; we just survive. And that, nature believes, is good.
We may think it odd that the Vietnam vet who was physically abused as a child was
more prone to come home from that war with PTSD (Scaer, 2001; Bremmer, et al,
1993). What kind of body makes that sort of adaptation? Actually, it’s not a silly
question. A body that learns from experience–for example, about how to be more
alert to danger the next time ‘round, how to react more quickly–is the sort of body
that would make the neural wiring modifications that mean to protect, but which
show up as PTSD. Those vets are simply pros at something they learned when they
were little. Their bodies learned to produce dramatically elevated levels of
adrenaline when exposed to abuse, and then to any stimulus that had characteristics
of this early trauma. Such adrenaline made them more prone to react, suddenly. It
also caused the release of more pain-modulating neurotransmitters, resulting in
reduced pain perception, which is good, except that this also created a kind of
dissociation from the body, sometimes leading to more risk-taking. It constricted
autonomic function (such as digestion) in favor of stiffening, alerting, and preparing
to take action. Focus and alertness increased, as did short-term memory, pupillary
dilatation and skeletal muscle tone.
All of this was good for survival, but not so good for ordinary living and learning;
instead, since the body wasn’t so sure when it was OK to turn off these enhanced
functions, it often remained in a state of hypervigilance, singular focus (which did
not, unhappily, translate into a capacity for focus on reading or other non-essential
tasks) and hypertonicity (which often lead to chiropractic problems, specific
musculo-skeletal inflammatory diseases, and fibromyalgia) (Scaer, 2001). Growth
was halted, in favor of using energy for more important things, like staying alive (or
what the body thought was staying alive). Levels of cortisol–a glucocorticoid that is
meant to modulate and regulate the acute effects of norepinephrine-induced arousal,
particularly on the limbic system–went up, which is a good thing, except that
cortisol tends to suppress the immune system, leaving the organism exposed to
disease (which is why, of course, abused children often have chronic colds) (Scaer,
2001).
Oddly, the same is true of victims of motor vehicle accidents. The likelihood of an
accident victim developing whiplash syndrome is far higher if that victim had been
abused as a child. Abuse tends to provoke the development of the freeze response,
and the tendency to dissociate. A grownup with this history is more likely to
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respond to a car crash with something akin to PTSD symptoms, often lasting for
years after even a minor accident–including difficulty in focusing and remembering,
headaches, irritability, sexual dysfunction, fibromyalgia and irritable bowel
syndrome (Scaer, 2001).
So it seems we are just not going to get away with perpetuating the myth of the
mind-body split any longer. These systems are interactive in ways that challenge
our diagnostic capacities, and make serious detective work needed to untangle the
causes of things. We can’t speak in simplistic terms–about “chemical imbalances”,
for example–when we know perfectly well that such “imbalances” do not arise out
of the blue. They occur–as do many diseases and conditions–because the body is
smart, and integrated, and has a nearly endless stream of options for negotiating
life, keeping the organism ready to react, and helping the organism to survive what
it imagines, at least, is out there.
And then, of course, we discovered two other little parts of the brain that are always
there to assure survival by giving their versions of stored information. The
hippocampus has several functions, including giving the brain a sense of the self in
space and time, and doing some organization of perceptions. But the biggie–the
assignment that makes the hippocampus show up so much in our work–is the job of
linking memory to meaning (Siegel, 1999). It essentially asks the question, in the
face of new experience: “Have I been here, before? If so, what was that experience
like, what coherent story about that event do I know, and what, therefore, can I
anticipate in the future?” The hippocampus has a major role in creating a narrative
of the self across time, in the service of helping us to feel coherent, to discern
patterns, to notice the familiar (even when it actually isn’t). Declarative, explicit
memory processing is possible because of the work of the hippocampus. Physical
damage to the hippocampus interferes with the ability to remember the context in
which the event occurred (Kandel, 2006).
We know that moderate levels of stress actually facilitate memory. But high levels
“...not only transiently block hippocampal functioning, but excessive and chronic
exposure to stress hormones may lead to neuronal death in this region” (Siegel,
1999, p. 50), producing decreased hippocampal volume. Indeed, this is exactly what
we found when we were finally able to look at the brains of war veterans with
PTSD–and, since then, at the brains of other victims of chronic and overwhelming
stress. Their smaller hippocampi were, then, less able to do their job of keeping the
organism informed and rational, with a coherent sense of self and self-with-other, by
reducing the availability of explicit, declarative memories. Memory became
fragmented, without detail, and without coherence. Other areas of the brain were
then left to fill in.
Enter the amygdala. A small, almond-shaped nucleus deep in the center of the
brain, it is, frankly, not too smart. On the other hand, it is quite essential to
survival. It is poorly-equipped to make sense of things; that’s just not its job. If
there’s time to process things, to consider them a bit, it will send sensory input on to
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the hippocampus and the orbitofrontal cortices, where they do that sort of thing,
and where they can pull off some rational response planning.
The amygdala itself, however, has one principal task: To yell loudly if it senses
danger. It has face-recognition cells that respond quickly to expressions of fear or
anger. It does not think about the meaning of the facial expression of another; it
merely reacts. And when it reacts, it creates a neurological feedback loop. When a
foster child’s amygdala picks up a cue suggesting danger on the face of another –or
in the gait, or the dress, or because of the beard or the pace of motor activity of
another–it tells the child to react, usually by freezing, or running or kicking out in
some fashion. This creates a response on the part of the other that the amygdala–
which is still on duty–senses, reacts to all over again, but also registers as an
affirmation that the first sensation of danger was correct. Later, it will be tough to
talk the amygdala out of its original perceptions, and a pattern of sensation and
primitive interpretation has been laid down.
Ask any foster or adoptive parent of a child with Reactive Attachment Disorder
whether this is true. Such parents are well-acquainted with the actions of the
amygdala, and with the pathetic insufficiency of using words to try to console the
reacting child.
And when the amygdala reacts, the stimulus and the feeling attached to it are both
kept in storage, not as a coherent memory, but only as a simple reminder that
something awful could happen if anything even vaguely like the thing stored in that
memory is ever encountered again. Thus the Iraq war veteran with PTSD who
jumps out of his skin when a kid shoots off his cap gun, may not respond in a
measured fashion. The amygdala is in charge. And the amygdala thinks it’s pretty
dumb to sit around pondering things.
In PTSD victims, this can get especially debilitating, as the feedback loop not only
keeps the person constantly on edge and reacting, but may itself become self-
perpetuating: threat-related information may begin to be generated internally,
through flashbacks, intrusive memories and nightmares. So good luck to the
adoptive mom who tries to convince a child who has experienced five foster
placements that he has made erroneous conclusions about whether attachment is
safe.
Now, the activities of these two brain structures may not sound particularly
adaptive. But can you imagine how we could function–much less stay alive–without
them? What if we only had the hallowed frontal cortices–or, worse, only the
comparatively sluggish, thoughtful, all-processing left frontal cortex–to rely on,
when a decision has to be made soon, in order for the organism to make it to lunch.
(“Hmmm...The building seems to be on fire. What options do I have? Shall I do
this? No, that might not work. Let’s see here...”) You can hardly blame these
limbic structures if they sometimes get it wrong and cause us to not be able to sit
still, or accept love, or filter out extraneous stimuli and concentrate on homework,
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or stop screaming when something goes off in our brain and we think we are about
to be left...again.
In discussing the increased responsiveness of the hypothalamic-pituitary-adrenal
axis-the HPA axis–of mothers stressed during pregnancy (which imbues the pre-
born baby with personality traits and behavior patterns it may not have had
before), Dr. Marcy Axness teaches us that the objective of prenatal arousal is to
teach the baby about the world, to warn the baby about imminent danger, to
prepare the baby’s entire emotional and physical self to be ready for what it may
encounter after birth. She asserts, “What I have just described is nature’s perfect
system for keeping offspring alive in the animal kingdom: when a giraffe is pregnant
during a particularly heavy lion season, for example, her calf will need two strong
tendencies to remain alive: 1.) the hyper-reactivity of a sensitive stress axis, and 2.)
the disinclination to ‘stop and smell the roses’, to relax and enjoy the finer things in
life...lest he be caught unawares and end up as dinner on the savannah.” (Axness,
2003, p. 87). Indeed, if we suffer physical damage to the amygdala, we lose much of
our capacity to respond emotionally to emotionally charged external stimuli
(Kandel, 2006); ironically enough, that may make us less resilient.
Siegel’s paradigm about memory would suggest that the unborn giraffe
“remembers” the heavy lion season, and the lessons mom passed on about how to
cope with such dangers. He states, “Memory is more than what we can consciously
recall about events from the past. A broader definition is that memory is the way past
events affect future function” (italics his) (Siegel, 1999, p. 24).
So we don’t always make the most adult decisions about how to adapt, when we are
little; we just make the decisions that seem to make sense at the time, so that we can
survive. The little girl who loses her daddy when she is one year old, and grows up
to date only boys who are likely to use her and then leave, is not being too smart, we
would say. But she is doing what she knows. And we’re probably not going to talk
her out of it.
One of the most striking examples of this sort of resilience–this remarkable capacity
to adapt, in order to survive–is seen in children with Reactive Attachment Disorder
of Infancy and Early Childhood. These kids truly drive their foster or adoptive
parents crazy. Rates of placement disruption for children with RAD are
outrageously high. They often reserve their most profound hate, and most disruptive
behavior, for their foster or adoptive mothers.
And they drive us a little diagnostically crazy, as well, by not having the good grace
to all look alike. Some are withdrawn and inhibited, while others are
indiscriminately sociable. Many are highly intelligent, and often manipulative, while
others are listless and uninvested in either people or inanimate objects. Some display
delayed bone age or other signs of poor physical or mental development, while
others are of normal stature and may even be precocious in one or another area of
development. Some are overtly cruel, and will deny culpability even when caught
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red-handed. Others are more sly. Some are immensely charming, while others lack
even basic social skills. Some experience extreme anxiety, with consequent problems
in focusing and concentration and a tendency toward nightmares, while others
display a startling absence of anxiety, even in stressful circumstances. Nearly all
have deficits in their capacity for giving or receiving affection. Most are self-
destructive, with behaviors ranging from self-biting, to pulling out hair in clumps, to
putting themselves repeatedly in harm’s way.
Most show severe deficits in the capacity to experience empathy for others,
manifestations ranging from cruelty to animals or babies, to chronic blitheness
about the pain of others. Some steal, hoard or gorge on food (and sometimes non-
food items). One of the behaviors particularly likely to put the foster or adoptive
parent over the edge is “crazy-lying”, which is a chronic, undifferentiated,
sometimes ridiculous effort to avoid culpability for anything. Some display unusual
patterns of eye contact, frequently characterized by gaze aversion. A significant
percentage display a high level of interest in fire, blood, and gore. Nearly all barely
contain a smoldering rage.
Children with RAD have usually experienced a profound level of chronic neglect,
physical and/or sexual abuse, some kind of separation from—or loss of—the
primary attachment figure (if there ever was one) and, most often, an additional
element: some sort of trauma, mixed with the abuse or neglect or loss. The trauma
can be a one-time event (watching mom shake another baby in the family to death),
a systematic pattern (repeated beatings and torture, or denial of human touch and
stimulation) or it can actually be created by the system designed to “save” the child
from such maltreatment: repeated placement disruptions.
As if to affirm, right out of the diagnostic chute–that the crazy-making child with
RAD is being entirely sensible, Dr. Axness suggests a new nomenclature: NORMAL–
Natural, Organismic Response to Massive Abandonment or Loss.
We were just beginning to hear about these children 20 years ago. In the years
since, we have seen the emergence of an entirely new spectrum disorder, the
emergence of several radical treatments (and the failure of most of the traditional
interventions), the arousal of ire and indignation on the part of misled foster and
adoptive parents, and the rising up of a new metaphysics of childhood disorder:
These kids really drive home the point that, if you look carefully, every single one of
their behaviors and their unusual affects make sense.
Imagine what it would mean to our clinical practice with these children if we really
did assume that there was evidence of resilience--evidence of adaptation--in their
strident refusal to ever take responsibility for anything; in their violent rages at
mother; in their sly, sneaky, charming natures in grade school; in their inability to
focus.
Right now, these children are fraequently inadequately diagnosed with ADHD and,
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later, Oppositional Defiant Disorder, Conduct Disorder and–in recent years–with
Bipolar Disorder. Why are these inadequate diagnoses? Not because, functionally
speaking, they don’t apply. They often do. But because they say nothing about the
key issue in understanding RAD, and the children who manifest it: It is an adaptive
disorder. Something happened, the organism took note, and the organism did what
organisms are designed to do: to react, to adapt, to survive. How would public
policy, child welfare policy, program planning and clinical practice change if we
acted as if we understood this?
Indeed, what if we took this position about a great many childhood disorders? We
now have neurodevelopmental research that affirms the principle: most things kids
do–including patterns of behavior that last a lifetime–actually represent the very
best efforts of an organism (albeit, perhaps, a primitive, non-verbal organism) to
make sense of his world at the moment, and to adapt to it. The man who is having
an affair with his 28-year-old secretary—a secretary who happens, it turns out, to
look just like the woman in the crumpled picture in his wallet, the adopted man’s
birthmother, who happened to be 28 when she relinquished him—is a man on a
search. Unless we can image him as a lost newborn, watching the only mother he has
ever known go away from him, struggling to catch on to the new kinesthetic
rhythms and smells and sounds of his new, adoptive mother, then we will only
choose to deal with the present-day marital issues that seemed to precede the
commencement of the affair. We will miss the whole point. We will miss the adapting
baby in the picture and, thereby, we will miss the chance to help.
III. RESEARCH INTO THE NATURE AND ACTION OF GENES
We were trained that genes predict traits, and, by extension, are responsible for
behavior. The last 20 years of research–often led by unfamiliar colleagues in cellular
biology and organic medicine–has suggested something quite different: that genes
work more like switches, waiting to be turned on—or not—by, of all things,
experience. Nearly overlooked was the startling announcement, back in 1961, by
Francois Jacob of the Institut Pasteur in Paris, that genes could be regulated,
switched on and off like a water faucet (Jacob and Monod, 1961; mentioned in
Kandel, 2006, p. 256). It took years for this idea--much less the biology that
demonstrated it--to seep into our training in developmental psychology. Myron
Hofer, Director of the Sackler Institute for Developmental Psychobiology at
Columbia, states without equivocation, “You have to have the environment...[for]
the predisposition to be expressed” (Tortora, 2004, p. 16).
And now we have a body of research in epigenetics: the study of the ways
environment impinges on genetic expression. So profound are the possibilities in
epigenetics that not only is there exploration of the minutae of intrauterine social
and biological life, but there is interest in differences in the IVF culture medium—
the “soup” in which embryos grow in the laboratory, after in-vitro fertilization
(Kolata, 2009).
12
So, instead of lying around, being controlled by our genes, it turns out that we are,
as prenates and babies, constantly adapting, changing our genetic makeup and our
neural wiring, to better live in our world–at least as we perceive it. We are plastic.
We are adaptive. As molecular biologist Eric Kandel puts it: “Even identical twins
with identical genes have different brains because of their different life experiences”
(Kandel, 2006, p. 218).
In this context, “environment” is not, of course, an objective phenomenon. We
define our experience through our perception of it. And that perception is very
much shaped and limited by the perceptions of our mother, while we are in utero;
and later, by all of our caregivers; and by prior experiences which we may deem
similar to the present event. This is, for example, why domestic violence hurts
unborn babies so much. The entire experience of mom being beaten–or her
screaming, or her cowering–is organically transmitted to the baby inside her. That
baby’s neural wiring changes. He learns, before he is ever born, how to hide away
and not be detected, lest he cause further bother to an already distressed mother; or
to lash out noisily, lest danger sneak up on him.
So life is not quite as predetermined as we imagined. And we have to live with the
public policy and clinical practice implications of the fact that childhood disorders
are often not “just physical”; much less are they plainly “genetic”. They may have a
physical component, but it will be hard to untangle, later, just what caused what.
And they may have a genetic component, but it was not the gene that caused the
emergence of the disorder. It was the transaction between a genetic predisposition
and actual experience: in other words, life.
Consider this: even if we were to isolate a “gene for violence” (which, it turns out, is
highly unlikely), we would still be stuck with trying to explain how a certain child
with such a genetic makeup turned out to be as peaceful as a lamb–simply because
he happened to grow inside an unusually peaceful mom, who later touched and
cuddled him in just the way he needed. A child with a genetic predisposition for
shyness or withdrawal may turn into a fighter, because her environment was
sufficiently terrifying that survival seemed assured only if she loudly defended
herself. A child with a gene for cancer may never get the disease, because he
happened to grow up in an area with few carcinogens in the air, while a sibling, with
the same gene, may be stricken in his 50's, because of the happenstance of spending
every summer, as a child, with relatives who lived near a particular type of
smokestack.
We have known for some time that low levels of the enzyme momoamine oxidase A
(MAOA), which is coded by a particular gene, are associated with criminality and
violence. At one time, scientists even wondered if this might be the elusive “violence
gene”. Knocking out the MAOA gene in mice makes them more aggressive (Restak,
p. 209). Boys with low MAOA activity are twice as likely to develop conduct
disorders, and three times as likely to commit a violent crime by age 26. But the
13
trigger for expression of this gene is childhood physical abuse. In the absence of this
trigger, there may be low levels of MAOA, but no violence (Restak, p. 209). Abuse
“turns on” the genetic marker.
Experience rewires our brains, changes our genetic makeup, supports the
development of new traits and the selection of new behaviors. This is the level of
plasticity we now know characterizes this amazingly flexible, dynamic, interactive
organ that sits atop our necks. Nobel prize-winning researcher Eric Kandel makes
sure we understand that life does not just pathetically knock on the door of the
brain, asking to please be acknowledged. It announces itself, and we change our
minds, anatomically. Complex transactions among proteins around synaptic
connections lead to the switching on of some genes, and the switching off of others,
along with physical changes in the structure of cells. The bottom line: “...even
though I had long been taught that the genes of the brain are the governors of
behavior, the absolute masters of our fate, our work showed that, in the brain as in
bacteria, genes also are servants of the environment. They are guided by events in
the outside world” (Kandel, 2006, p. 264.
While lecturing in the Netherlands a few years ago, I stumbled across a particularly
curious example of this phenomenon. During the Dutch “Winter of Hunger” in late
1944 and early 1945, the German occupation put strict controls on the food supply,
limiting most Dutch citizens to 400-800 calories per day.
Guess what happened to babies being gestated during that period of deprivation? A
great many of them were born with disproportionately big heads and small bodies,
and grew up to be obese. Their little unborn bodies detected the lack of food, and re-
shaped the system for distributing the available nutrition. Human adaptation
prefers brain development over the rest of the body. So food was shunted off to these
prenates’ heads, in order to assure survival. The size and shape of their bodies,
encoded in their genes, was changed, in utero.
Not only were these babies born with disproportionately large heads and small
bodies, but their livers changed the way they operated, in response to environmental
demands. These livers, trying to protect the lives of the unborn babies in which they
resided, began to predict that inadequate caloric intake would continue. They
converted more of the incoming food to fat, struggling to store it for future needs,
and unable to process it for daily use. The children grew obese, and, as adults, had
elevated cholesterol (Jones and Friedman, 1982; Lumey, et al, 1992; Ravelli, A., et
al, 1998; Ravelli, G., et al, 1976; Stein, et al, 1975; Winick and Noble, 1966). The
livers meant to protect the children from certain starvation, and they probably did.
But they also condemned the children to be unable–later, when there was plenty of
food–to change expectations back to normal. It turns out that when you’re little, and
every system in your body fights to keep you alive by whatever means are available
to you, you have a hard time letting it go, later.
This kind of plasticity, this enormous capacity for adaptation, this resilience, is
14
wondrous. But taking it into account changes clinical practice, changes how we view
troubling behavior. The little boy in a preschool center, having just experienced the
torching of his mom’s trailer by his daddy–an event that was only the latest chapter
in a long story of domestic violence–has begun changing his own makeup, to be
more alert to danger, to fight or run better, even to make himself unnoticed so he
won’t be hurt. You can see it, in real-time on an fMRI. A certain kind of childhood
nursery tale may later evoke, in this particular boy, memories of that fire and that
fear, producing a bright-red image–indicating significant blood flow–in motor
centers in the brain. He is preparing to run, years later. Another little boy, reading
the same nursery tale, shows oxygenated blood increasing in receptive language
centers, and areas associated with the processing of feelings in the right frontal
cortex. But not this little boy.
This is not the little boy his genes originally planned for him to become. But it is the
little boy he has become, because he is designed to re-make himself, on-site, to make
himself better equipped to cope. So, he is likely to be highly agitated at preschool,
easily set off by noises that are barely noticed by others, likely to go into a rage if he
encounters a bee or other flying insect (which overwhelms his frail but hair-trigger
defenses, making him feel powerless and terrified). He may try to set fires, repeating
one of his own experiences of trauma, as a way to understand and integrate it. He
may drive his mom crazy by fretting incessantly about the gas gauge in the car,
remembering (far better than mom does) her earlier terror when daddy used to
drain the tank so she couldn’t go anywhere. All of these behaviors are likely to
confuse both family and teachers.
When this child is brought to us, are we ready to see the adaptive meaningfulness of
his behavior? Are we going to head down the standard intervention path–one that is
unlikely to work if the diagnosis misses the point, thus further frustrating the
family and the teachers, and leaving the child without the responses that he needs?
And will we get it when, in a few weeks, he begins attacking the baby brother in the
family, or beating the pet bunny with a rock? Will we know to find out whether his
mom ever happened to tell him–perhaps in despair, or out of her own rage– that he
was just like his father?
IV. CONCLUSION
We have only begun to scratch the surface, today, about the exhilarating progress
made in the past 20 years about how early development works, about the influences
of attachment on development, about the nature of mind.
The work on co-regulation, for example, shows us just how astonishingly effective
are the nuances of infant-parent interaction in fine-tuning the mind of the infant.
Daniel Siegel reports:
Attachment at its core is based on parental sensitivity and responsibility to the
child’s signals, which allow for collaborative parent-child
15
communication....Contingent communication relies on the alignment of
internal experiences, or states of mind, between child and caregiver. This
mutually sharing, mutually influencing set of interactions–this...mental state of
resonance–is the essence of healthy, secure attachment (Siegel, 1999, p. 117).
So the baby learns when to be afraid, and how to find comfort; what dysregulation
feels like and what are the mechanisms for a return to homeostasis; how to read the
environment, and store information for future use. This may work out well, or not
so well. But the infant never stops trying to adapt by attending, by giving meaning
to each experience to which it has been aroused, by trying to develop a coherent
narrative.
These early applications of meaning tend to stick–not because the mind lacks
plasticity, because it has plenty of that, but because the mind tends to give meaning
to new experience in light of the meaning already attached to earlier experience that
it imagines to be (in its search for coherence) familiar. So a child who survives his
mother’s attempt to abort him may well select the adaptive path–he is, after all, no
dope–of becoming very quiet in the uterus (as if going unnoticed would increase his
chance of not being killed). Later, when he’s four, we notice that he is a kid who
never speaks up. All the cajoling of the family about what a fine and sweet child he
is will fail to increase his esteem. All the reminders to speak up, to assert himself,
will fail to get him to drop his shy and retiring demeanor, or his self-deprecating
words. He gave early meaning to an experience, and his mind has, so far, been
unwilling to take in new information, so that he could change his mind about
whether he will be safe if he is assertive, if he is seen.
These discoveries don’t seem to be slowing. Providing yet further evidence of the
fact that not only are our bodies not separated from our minds, but that our minds
are not even very separated from the minds of others, mirror neurons were
discovered when we found, accidentally, that motor neurons would fire in the brain
of one animal while that animal watched another animal move. The observing
animal never moved a muscle, but you would think he had, if you had been
watching his brain, at the time (Blakeslee, S, 2006).
A modern understanding of mind would suggest that this only makes sense. If we
are, as I have been asserting, organisms of survival, which we accomplish with
endless varieties of adaptation, then of course we would come equipped with
mechanisms for acquiring information about what others are doing–an acquisition
process that even invokes a capacity to neurologically mimic an other. As Dr.
Rizzolatti, one of the researchers at the original macaque project at the University of
Parma (where the mirror neuron phenomenon was first noticed) put it, “We are
exquisitely social creatures. Our survival depends on understanding the actions,
intentions and emotions of others....Mirror neurons allow us to grasp the minds of
others not through conceptual reasoning but through direct simulation. By feeling,
not by thinking” (Blakeslee, 2006, p. 1).
16
Are these mirror neurons the source of empathy? Are these the neurons that are in
short supply in children with some forms of autism? Is this how Brazleton got those
newborns to stick their tongues out at him, 30 years ago? It remains to be seen. In
the meantime, we have just one more reason to be awestruck by how connected we
are to ourselves, and to others.
We have learned that the young human child—the prenate, the newborn, the baby,
the toddler—is an astoundingly capable creature, who feistily struggles to adapt,
whose brain is so plastic that he can literally remake himself in order to cope with
what goes on in the uterus or the house in which he lives. Our challenge is to see how
we can let these developments of the past 20 years inform our work, inform our
perception of the child in trouble, engender appreciation and respect for the way in
which unusual, disruptive, aberrant or outrageous behavior in children and adults
may represent the work of a coping organism to stay alive.
Can we cope? Can we stand the implications? Can we stop compartmentalizing
human beings, stop trying to see them in physical dimensions that are separate from
emotional or even spiritual dimensions? Can we listen to babies? Can we listen to
parents who most assuredly used to be babies, and have never told their stories?
Can we stand the complexity revealed when we read the implications of modern
science: that behavior is meaningful, that the mind and body influence each other
constantly, and that the environment is constantly provoking changes in things we
used to think were fixed (genes, and the anatomy of the brain)? In discussing the
“causes” of suicide, Harvard’s Jerome Kagan forces us to acknowledge that the very
word (“cause”) is overrated and misunderstood:
...intense feelings of depression occur in children when early parental abuse,
lack of social support, and a genetic vulnerability that affects the amount of
serotonin in the brain are combined. In this and other examples there is no
single cause. The probability that an adolescent exposed to all three conditions
will develop this profile is very low, and only one or two of every hundred
children encountering these conditions will become depressed and suicidal
during the adolescent years. Depression, chronic delinquency, hyperactivity or
panic attacks...require an improbable blending of relevant conditions joined at
the proper times. Few psychological profiles have the causal properties of a
window shattered by a baseball (Kagan, 2006, pp. 94-95).
Stated more positively, can we begin to delight in the complexity of mind, in
the poetry of continuous, interweaving transactions between experience,
brain function, brain anatomy, and the action of the human mind? And
can we take pleasure in finally being able to peek into the meaning of
behavior in individuals and across whole societies?
Finally, how shall we respond to another undeniable implication of the
intense work in independent fields as disparate as molecular biology and
17
neurology: We are interdependent. Every "culture" studied in the last two
decades has shown us the evidence over and over again: from the
"culture" of a particular child in his several societal contexts, with a
particular experiential history, living with a particular foster family with
their own experiential history, to the larva of a certain snail that must--in
order to change in body form into "adulthood"--rest on a particular species
of red seaweed and be exposed to a certain chemical that triggers
metamorphosis (Kandel, 2006, p. 253). Nature's members lean on each
other, sometimes without even knowing we are doing it. We transact,
constantly. The butterfly effect is evident, everywhere. We are
interdependent. The political implications alone--not to mention those for
contextualizing our assessments of children and our treatment of individual
patients--are mind-boggling.
I broke into psychology 40 years ago next April, at an old-time, 6,000-patient state
mental hospital in the midwest. On the day I began my career, Bobby Kennedy was
speaking at the City Club of Cleveland. Martin Luther King had been killed the
day before. Bobby was exactly two months away from being gunned down, himself,
as he addressed the crowd, “On the Mindless Menace of Violence”:
...Whenever any American's life is taken by another American unnecessarily -
whether it is done in the name of the law or in the defiance of the law, by one
man or a gang, in cold blood or in passion, in an attack of violence or in
response to violence - whenever we tear at the fabric of the life which another
man has painfully and clumsily woven for himself and his children, the whole
nation is degraded.
...Yet we seemingly tolerate a rising level of violence that ignores our common
humanity and our claims to civilization alike. We calmly accept newspaper
reports of civilian slaughter in far-off lands. We glorify killing on movie and
television screens and call it entertainment. We make it easy for men of all
shades of sanity to acquire whatever weapons and ammunition they desire.
...Some look for scapegoats, others look for conspiracies, but this much is clear:
violence breeds violence, repression brings retaliation, and only a cleansing of
our whole society can remove this sickness from our soul.
...We learn, at the last, to look at our brothers as aliens, men with whom we
share a city, but not a community; men bound to us in common dwelling, but
not in common effort. We learn to share only a common fear, only a common
desire to retreat from each other, only a common impulse to meet disagreement
with force. For all this, there are no final answers.
Oh, how I miss him.
I believe this is why we study babies. If it isn’t, yet, for you, let it become the reason.
We study human adaptability in order to discover, finally, the way toward
18
understanding each other. We study attachment because we have not given up on
love. I fear that we have lost, as a nation, the capacity to know of the sorrow in the
heart of the Muslim child who picks up a gun. I fear we lost our wits, somewhere
along the line, about the obvious: If we kill people, their minds might just store that
information, and deliver it to the succeeding generations. It might be two
generations until a child who watches his brother and his mother shot in front of
him by Westerners manages to grow up, turn his rage into religious teachings, find
some other injured souls, and join with them to come bomb us. How hard is this to
understand? Even if our hearts have lost these common sense truths, science now
leads the way to tell us it is so: People don’t forget. Trauma lasts. The mind must
retaliate, somehow, somewhere, someday.
We allowed ourselves to be played like fiddles after 9-11. We turned into frightened
children, and we clapped when daddy told us he would go beat up the bad guys–any
bad guys–for us. People who know how to manipulate, in order to increase their
own power, saw our weakness and our fear, knew the somatic markers (Damasio,
1994) they could pluck, and we gave them the right to determine whether or not our
grandchildren would die, or–just about as awful–survive in a country no longer free,
closed down by its own fear and anger.
This science, this good news of the human capacity for love and adaptation, this
commitment to assuring that babies are cradled and their parents are held up–this
is the secret to the survival of our civilization. Surely it must be why we do what we
do, and why we should take such joy in it, every day.
Kennedy concluded:
...But we can perhaps remember, if only for a time, that those who live with us
are our brothers, that they share with us the same short moment of life; that
they seek, as do we, nothing but the chance to live out their lives in purpose and
in happiness, winning what satisfaction and fulfillment they can.
...Surely, this bond of common faith, this bond of common goal, can begin to
teach us something. Surely, we can learn, at least, to look at those around us as
fellow men, and surely we can begin to work a little harder to bind up the
wounds among us and to become in our own hearts brothers and countrymen
once again.
19
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