A Model for Caregiving of Adopted Children After Institutionalization

Journal of Child and Adolescent Psychiatric Nursing, Feb 2007 by Gribble, Karleen D

TOPIC: Optimizing caregiving for newly adopted postinstitutionalized children.

PURPOSE: To consider a template of care for postinstitutionalized children based on experiences that physiological measures suggest are expected by infants postbirth.

SOURCES: Published literature and clinical experience.

CONCLUSION: Based on an understanding of physiologically expected care postbirth, special care for postinstitutionalized adopted children might include: close physical contact via use of a sling and cosleeping; breastfeeding or nurturing through food; and responsive caregiving. In replicating earlier missed experiences, parents may assist emotional development in their child and promote attachment development.

Search terms: Institutionalization, attachment, physiology

Introduction

The number of children adopted worldwide via intercountry adoption is increasing each year, and the most recent statistics indicate that more than 20,000 children were adopted to the United States alone (U.S. State Department, 2005). These children have lost family, previous caregivers, familiar environments, and language, and many have also experienced some time in institutional care. Such children, with their history of loss and institutionalization, have special needs.

The experience of a child in an institution is very different from that of a child in a family. Although institutions vary widely in the quality of care they provide, they generally have high child-to-caregiver ratios, which do not allow for individualized attention. They may also be lacking in heating, cooling, space, toys, or nutrition and provide a restricted and regimented environment (Chisholm, 1998; Rutter & Team, 1998; Sloutsky, 1997). The physical and emotional deprivations of institutionalization can result in a raft of problems, including attachment difficulties, physical and developmental delays, and language and sensory integration issues (Chisholm; Fisher, Ames, Chisholm, & Savoie, 1997; Glennen, 2002).

It can be argued that the most serious deprivation of institutionalization is the lack of a consistent and sensitive caregiver whom the child can trust and form a healthy attachment to. Development of a secure attachment normally occurs through interactions in which a primary caregiver meets a child's needs in an appropriate manner resulting in reduction of discomfort and in feelings of relief (Levy & Orlans, 2000). This cycle of need-arousal-gratification-relief-need is ordinarily repeated many thousands of times in the first years of a child's life but is absent or greatly reduced in the experience of children in institutions (Chisholm, 1998; Fisher et al., 1997; Levy & Orlans). Attachment theory is the primary paradigm within which the impact of the absence of a responsive, consistently available caregiver on the behavior of institutionalized children is understood (Gunnar, Bruce, & Grotevant, 2000), and the research presented in this paper has relied upon this framework.

Parenting a newly adopted postinstitutionalized child can be extremely difficult, as along with any issues that may exist as a result of institutionalization, the child may also be grieving and be traumatized by their placement. In addition, friends and healthcare professionals with little understanding of the experience or needs of postinstitutionalized children may deluge new parents with contradictory or inappropriate advice. Determining how to meet the needs of their postinstitutionalized child and assist attachment development is of great concern to adoptive parents, and the care that children receive in the immediate postplacement period can significantly impact long-term outcomes (Gunnar et al., 2000).

This paper will present a hypothesis that a suitable template for care for newly adopted children is to seek to replicate many of the early experiences that physiological measures suggest are expected by infants postbirth. In newborn babies, when this "expected" physiologically congruent care is provided, a physiological interdependence between mother and child is created. This physiological interdependence impacts mother and child in ways that can be viewed as positive for both of them and promotes responsive caregiving and attachment development. While this care is usually provided in the first year of a child's life, it may be that aspects of physiologically congruent care can be applied to the care of older baby to school-aged postinstitutionalized children and may optimize the opportunity for development of the attachment relationship. The presentation of this hypothesis follows.

Physiologically Congruent Care for Infants

While there are many models for infant care that vary depending on cultural and ideological beliefs (Small, 1998), there is evidence that maternal separation is stressful for infants and that physiological congruent care, involving close physical contact between mother and child and frequent suckling at the breast, is ideal.

Maternal Recognition

At birth, healthy babies placed on the abdomen of their mother will crawl up onto her chest and locating the nipple via smell will attach to her breast and suckle (Klaus, 1998; Righard & Alade, 1990). Breast secretions are attractive to newborns because they overlap in chemistry with that of the amniotic fluid of their mother and are therefore familiar (Porter & Winberg, 1999). Babies become familiar with their mother's voice in utero (Fifer & Moon, 1994) and within a short time of birth learn to recognize and prefer looking at her face (Bushnell, Sai, & Mullin, 1989; Walton, Armstrong, & Bower, 1997). Thus, babies know their mother at birth and when removed from skin-to-skin contact with her give a specific "separation distress cry/call" indicating their desire for reunion (Christennson, Cabrera, Christensson, Uvnas-Moberg, & Winberg, 1995). In animal models such separation results in stress hormone release (Rosenfeld et al., 1991; Laudenslager et al., 1995).