Correlation of Neurocognitive Disorders, FASD, TBI and Social Reciprocity
By Dr. Ronald S. Federici, Board Certified Developmental Neuropsychologist
Professor of Pediatrics , Neurology and Psychiatry-Military School of Medicine
While the role of the Developmental Neuropsychologist is to evaluate intellectual-cognitive, memory processing, learning aptitude, and problem-solving strategies, a critical duty may actually be in the evaluation of a child’s emotional integrity and perception of relationships. The interplay between neurocognitive development and emotions encompasses basic neurobiology which suggests that human emotions, reactions, interactions and attachments may be strongly mediated by a combination of genetic, neurochemical, neurocognitive and environmental factors. As there has been a tremendous amount of discussion regarding “attachment disorders” in the post-institutionalized child, the current psychological research focuses almost solely on the effects of deprivation and abandonment and the creation of an “attachment disorder” without a more detailed understanding of the role of innate neurocognitive functioning.
While abandonment and institutionalization most certainly has a profound impact on a child’s ability to develop trust, bonding and security in newly adoptive relationships, an emphasis needs to be placed on the integrity of the post-institutionalized child’s higher-level neurocognitive abilities with a comprehensive assessment regarding the availability of “innate skills” needed for bonding, attachment and the development of appropriate social-interactional and reciprocal behaviors. While many children with post-institutionalized attachment disorders may display a combination of unattached or even indiscriminant behaviors (Ames, 1997), many post-institutionalized children display a very intense pattern of behavioral dyscontrol; aggression and violence; destructiveness to self and others; a lack of cause-and-effect thinking; indiscriminant affections to strangers as evidenced by being inappropriately demanding and clingy; or a pattern of social withdrawal, isolation and maintaining a self-stimulating posture. A principle complaint from parents adopting an older child is that the child may be out of synchrony with their environment resulting in difficulties in providing management, structure and organization.
The concept of a “neuropsychologically-based attachment disorder” seems most appropriate for many post-institutionalized children, particularly the child who shows a history of high risk pre and post-natal factors which may have influenced neurocognitive development. For example, there is a documented interaction between growth parameters and neurologic competence in profoundly deprived institutional children assessed in Romanian institutions (Johnson and Federici et.al., 1999). Children who have shown documented medical and neurological impairments along with extended time in institutional settings typically display very pronounced impairments in the development of appropriate social-interactional skills. Combined with suspected impairments in neuropsychological abilities, behavioral patterns can often be quite aberrant and intense in nature, often overwhelming the newly adoptive family.
Therefore, it seems only appropriate to broaden the horizon when assessing children for bonding, attachment or general psychological dysfunction by including a comprehensive assessment of neurocognitive abilities or deficit patterns. As children from institutional settings are at highest risk for medical, neuropsychological and emotional problems, an assessment of only the psychological or behavioral manifestations provides only a partial understanding of the adjustment issues which often produce tremendous stress on the newly adoptive families and treatment providers attempting to intervene and provide services (Johnson, 1997; Federici, 1999).
Careful differential diagnosis regarding neuropsychological versus psychosocially-based attachment disorder can help provide newly adoptive families with better parameters of understanding the post institutionalized child. Additionally, neuropsychological and neurocognitive rehabilitation approaches should typically supersede solely psychological or psychiatric/pharmacological therapies as providing direct interventions and increasing speech and language, sensory-motor, abstractive logic and reasoning and, of greatest significance, visual-perceptual analytic abilities. These brain behavior interventions strengthen the post-institutionalized child’s ability to adequately “perceive” and process human relationships, emotions, facial expressions, social cues, and the necessary sequential “steps” needed to move towards a more healthy level of bonding and attachment. Too often, children from institutional settings are quickly categorized as having either a “reactive attachment disorder” or modicum of psychiatric syndromes ranging from Attention Deficit Hyperactivity Disorder, Bipolar Disorder, Post Traumatic Stress Disorder, varying types of depression and anxiety conditions or, very commonly, oppositional and conduct disorders or even autism/pervasive developmental disorders. While many of these psychiatric patterns may be co-morbid conditions, there needs to be a very aggressive but yet conservative approach in assessing the post-institutionalized child. Rank ordering developmental disabilities of the child as opposed to relying solely on the assessment of families or treatment providers may avoid misleading diagnoses and nonproductive therapeutic interventions.
References
Ames, E.W. (1997). The Development of Romanian Orphange Children Adopted to Canada. Burnaby, B.C. , : Simon Frasier University.
Battiata, M. (1990a). A Ceausescu Legacy: Warehouses for Children. The Washington Post, June 7, A1-A34
Battiata, M. (1990b). 20/20: Inside Romanian Orphanages. The Washington Post, October 5, D3
Bowlby, J. (1951). Maternal Care and Mental Health. World Health Organization Monograph Number 2. Geneva: World Health Organization
Cermak, S. and Daunhauer, L. (1997). Sensory Processing in the Post-Institutionalized Child. The American Journal of Occupational Therapy, 51, 500-507
Doolittle, Teri (1995). The Long-Term Effects of Institutionalization on the Behavior of Children From Eastern Europe and the Former Soviet Union. The Post: Parent Network for the Post-Institutionalized Child, March
Federici, Ronald S. (1998). Help for the Hopeless Child: A Guide for Families (With Special Discussion for Assessing and Treating the Post-Institutionalized Child
Federici, Ronald S. (1997). Institutional Autism: An Acquired Syndrome. The Post: Parent Network for the Post-Institutionalized Child, November, Volume Fourteen
Galler, J. and Ross, R. (1998). Malnutrition and Mental Development. The Post: The Parent Network for the Post-Institutionalized Child; Volume 6: 1-7
Immigration and Naturalization Service (1998), Immigrant Orphans Admitted to the United States by Country of Origin or Region of Birth, 1989-1998. Washington, D.C.: U.S. Department of Justice
Kifner, J. (1989). Army Executes Ceausescu and Wife for Genocide Role. The New York Times, December 26, A1-A16
Johnson, D., Miller, L., Iverson, S., Thomas, W., Dole, K., Georgieff, M. and Hostetter, M. (1992). The Health of Children Adopted from Romania. Journal of the American Medical Association, 268-3446-3451
Johnson, D., Albers, L., Iverson, S., Dole, K., Georgieff, M. and Hostetter, M., and Miller, L.C., (1996). Health Status of Eastern European Adoptions Referred for Adoption, Pediatric Research, 39, 134A (abstract)
Johnson, D.E. (1997). Adopting the Institutionalized Child: What Are the Risks? Adoptive Families, 30, 26-29.
McGuinness, T. (1998). Risk and Protective Factors in Children Adopted From the Former Soviet Union. The Post: Parent Network for the Post-Institutionalized Child:8, 18, 1-5
Miller, L. and Klein, Gittleman, M. (1995). Developmental and Nutritional Status of Internationally Adopted Children. Archives of Pediatrics and Adolescent Medicine, 149, 40-44
Rutter, M. (1998). Developmental Catch Up and Deficit Following Adoption After Severe Global Early Privation. English and Romanian Adoptees (ERA) Study Team. Journal of Child Psychology and Psychiatry, 39, 465-476
Rutter, M. (1999). Quasi-Autistic Patterns Following Severe Early Global Privation. Journal of Child Psychology and Psychiatric (In Press)
Zeanah, C., Mammen, O. and Lieberman, A. (1993) Disorders of Attachment, In C.H. Zeanah (ed.): Handbook of Infant Mental Health (PP.332-349), New York, Guilford Press
Zeanah, C.H., (1996). Beyond Insecurity: A Reconceptualization of Clinical Disorders of Attachment. Journal of Consulting and Clinical Psychology, 64, 42-52
Zeanah, C.H. (1999). Disturbances of Attachment in Young Children Adopted From Institutions (in press).
