Adoption

Adoption
A guidebook
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Contents
Articles
Adoption
Language of adoption
19
Open adoption
23
Closed adoption
27
Domestic adoption
32
Foster care adoption
34
International adoption
35
Interracial adoption
42
Embryo donation
45
Foster care
48
Orphan
64
AIDS orphan
68
Orphanage
69
Third culture kid
85
Cultural variations in adoption
93
Child development stages
95
Ethology
110
Adoption home study
118
Child protection
119
Child abuse
126
Human bonding
137
Affectional bond
144
John Bowlby
145
Mary Ainsworth
151
Michael Rutter
156
Attachment theory
158
Attachment in children
182
Attachment measures
190
Attachment therapy
200
Attachment disorder
216
Maternal deprivation
227
Prenatal nutrition and birth weight
237
Anxiety
245
Emotional dysregulation
251
Posttraumatic stress disorder
252
Reactive attachment disorder
276
Disinhibited attachment disorder
290
Institutional syndrome
291
Fetal alcohol syndrome
293
Fetal alcohol spectrum disorder
307
Prenatal cocaine exposure
315
Cleft lip and palate
323
Disruption (adoption)
337
Genealogical bewilderment
340
Adoption in the United States
342
Adoption in Italy
346
Adoption in France
347
Adoption in Australia
348
Adoption in Guatemala
354
LGBT adoption
355
Child laundering
369
Trafficking of children
370
Adoption disclosure
372
Adoption reunion registry
374
Adoption tax credit
375
Aging out
376
List of international adoption scandals
378
References
Article Sources and Contributors
382
Image Sources, Licenses and Contributors
388
Article Licenses
License
391
Adoption
Adoption
Adoption is a process whereby a person assumes the
parenting for another and, in so doing, permanently
transfers all rights and responsibilities from the original
parent or parents. Unlike guardianship or other systems
designed for the care of the young, adoption is intended
to effect a permanent change in status and as such
requires societal recognition, either through legal or
religious sanction. Historically some societies have
enacted specific laws governing adoption whereas
others have endeavored to achieve adoption through
less formal means, notably via contracts that specified
inheritance rights and parental responsibilities. Modern
systems of adoption, arising in the 20th century, tend to
be governed by comprehensive statutes and regulations.
Adoption has a long history in the Western world,
closely tied with the legacy of the Roman Empire and
the Catholic Church. Its use has changed considerably
over the centuries with its focus shifting from adult
adoption and inheritance issues toward children and
family creation and its structure moving from a
recognition of continuity between the adopted and kin
toward allowing relationships of lessened intensity.
History
Sister Irene of New York Foundling Hospital with children. Sister

Irene is among the pioneers of modern adoption, establishing a
system to board out children rather than institutionalize them.
Adoption
Antiquity
Adoption for the well-born
While the modern form of adoption emerged in the United States, forms of the
practice appeared throughout history.[1] The Code of Hammurabi, for example,
details the rights of adopters and the responsibilities of adopted individuals at
length and the practice of adoption in ancient Rome is well documented in the
Codex Justinianus.[2] [3]
Markedly different from the modern period, ancient adoption practices put
emphasis on the political and economic interests of the adopter,[4] providing a
legal tool that strengthened political ties between wealthy families and creating
male heirs to manage estates.[5] [6] The use of adoption by the aristocracy is well
documented; many of Rome's emperors were adopted sons.[6]
Infant adoption during Antiquity appears rare.[4] [7] Abandoned children were
often picked up for slavery[8] and composed a significant percentage of the
Empires slave supply.[9] [10] Roman legal records indicate that foundlings were
occasionally taken in by families and raised as a son or daughter. Although not
normally adopted under Roman Law, the children, called alumni, were reared in
an arrangement similar to guardianship, being considered the property of the
father who abandoned them.[11]
Trajan became emperor of Rome

through adoption, a customary
practice of the empire that enabled
peaceful transitions of power.
Other ancient civilizations, notably India and China, utilized some form of adoption as well. Evidence suggests their
practices aimed to ensure the continuity of cultural and religious practices, in contrast to the Western idea of
extending family lines. In ancient India, secondary sonship, clearly denounced by the Rigveda,[12] continued, in a
limited and highly ritualistic form, so that an adopter might have the necessary funerary rites performed by a son.[13]
China had a similar conception of adoption with males adopted solely to perform the duties of ancestor worship.[14]
Middle Ages to Modern Period

Adoption and commoners
The nobility of the Germanic, Celtic, and Slavic cultures that
dominated Europe after the decline of the Roman Empire denounced
the practice of adoption.[15] In medieval society, bloodlines were
paramount; a ruling dynasty lacking a natural-born heir apparent was
replaced, a stark contrast to Roman traditions. The evolution of
European law reflects this aversion to adoption. English Common Law,
for instance, did not permit adoption since it contradicted the
customary rules of inheritance. In the same vein, France's Napoleonic
Code made adoption difficult, requiring adopters to be over the age of
50, sterile, older than the adopted person by at least fifteen years, and
At the monastery gate (Am Klostertor) by
to have fostered the adoptee for at least six years.[16] Some adoptions
Ferdinand Georg Waldmller.
continued to occur, however, but became informal, based on ad hoc
contracts. For example, in the year 737, in a charter from the town of Lucca, three adoptees were made heirs to an
estate. Like other contemporary arrangements, the agreement stressed the responsibility of the adopted rather than
adopter, focusing on the fact that, under the contract, the adoptive father was meant to be cared for in his old age; an
idea that recalls conceptions of adoption under Roman law.[17]
Europe's cultural makeover marked a period of significant innovation for adoption. Without support from the
nobility, the practice gradually shifted toward abandoned children. Abandonment levels rose with the fall of the
Adoption
empire and many of the foundlings were left on the doorstep of the Church.[18] Initially, the clergy reacted by
drafting rules to govern the exposing, selling, and rearing of abandoned children. The Church's innovation, however,
was the practice of oblation, whereby children were dedicated to lay life within monastic institutions and reared
within a monastery. This created the first system in European history in which abandoned children were without
legal, social, or moral disadvantage. As a result, many of Europe's abandoned and orphaned became alumni of the
Church, which in turn took the role of adopter. Oblation marks the beginning of a shift toward institutionalization,
eventually bringing about the establishment of the foundling hospital and orphanage.[18]
As the idea of institutional care gained acceptance, formal rules appeared about how to place children into families:
boys could become apprenticed to an artisan and girls might be married off under the institution's authority.[19]
Institutions informally adopted out children as well, a mechanism treated as a way to obtain cheap labor,
demonstrated by the fact that when the adopted died, their bodies were returned by the family to the institution for
burial.[20]
This system of apprenticeship and informal adoption extended into the 19th century, today seen as a transitional
phase for adoption history. Under the direction of social welfare activists, orphan asylums began to promote
adoptions based on sentiment rather than work, and children were placed out under agreements to provide care for
them as family members instead of under contracts for apprenticeship.[21] The growth of this model is believed to
have contributed to the enactment of the first modern adoption law in 1851 by the Commonwealth of Massachusetts,
unique in that it codified the ideal of the "best interests of the child."[22] [23] Despite its intent, though, in practice, the
system operated much the same as earlier incarnations. The experience of the Boston Female Asylum (BFA) is a
good example, which had up to 30% of its charges adopted out by 1888.[24] Officials of the BFA noted that, although
the asylum promoted otherwise, adoptive parents did not distinguish between indenture and adoption; "We believe,"
the asylum officials said, "that often, when children of a younger age are taken to be adopted, the adoption is only
another name for service."[25]
Modern period
Adopting to create a family
The next stage of adoption's evolution fell to the emerging nation of the United States. Rapid immigration and the
aftermath of the American Civil War resulted in unprecedented overcrowding of orphanages and foundling homes in
the mid-nineteenth century. Charles Loring Brace, a Protestant minister became appalled by the legions of homeless
waifs roaming the streets of New York City. Brace considered the abandoned youth, particularly Catholics, to be the
most dangerous element challenging the city's order.[26] [27]
His solution was outlined in The Best Method of Disposing of Our Pauper and
Vagrant Children (1859) which started the Orphan Train movement. The orphan
trains eventually shipped an estimated 200,000 children from the urban centers of
the East to the nation's rural regions.[28] The children were generally indentured,
rather than adopted, to families who took them in.[29] As in times past, some
children were raised as members of the family while others were used as farm
laborers and household servants.[30]
Charles Loring Brace.
Adoption
4
The sheer size of the displacementthe largest migration of children in
historyand the degree of exploitation that occurred, gave rise to new agencies
and a series of laws that promoted adoption arrangements rather than indenture.
The hallmark of the period is Minnesota's adoption law of 1917 which mandated
investigation of all placements and limited record access to those involved in the
adoption.[31] [32]
William and his brother Thomas.

They rode the Orphan Train in 1880
at the ages of 11 and 9, respectively.
William was taken into a good home.
Thomas was exploited for labor and
abused. The brothers eventually
made their way back to New York
and reunited.
During the same period, the Progressive movement swept the United States with
a critical goal of ending the prevailing orphanage system. The culmination of
such efforts came with the First White House Conference on the Care of
Dependent Children called by President Theodore Roosevelt in 1909,[33] where it
was declared that the nuclear family represented "the highest and finest product
of civilization and was best able to serve as primary caretaker for the abandoned
and orphaned.[34] [35] Anti-institutional forces gathered momentum. As late as
1923, only two percent of children without parental care were in adoptive homes,
with the balance in foster arrangements and orphanages. Less than forty years
later, nearly one-third were in an adoptive home.[36]
Nevertheless, the popularity of eugenic ideas in America put up obstacles to the growth of adoption.[37] [38] There
were grave concerns about the genetic quality of illegitimate and indigent children, perhaps best exemplified by the
influential writings of Henry H. Goddard who protested against adopting children of unknown origin, saying,
Now it happens that some people are interested in the welfare and high development of the human race; but
leaving aside those exceptional people, all fathers and mothers are interested in the welfare of their own
families. The dearest thing to the parental heart is to have the children marry well and rear a noble family.
How short-sighted it is then for such a family to take into its midst a child whose pedigree is absolutely
unknown; or, where, if it were partially known, the probabilities are strong that it would show poor and
diseased stock, and that if a marriage should take place between that individual and any member of the family
the offspring would be degenerates.[39]
It took a war and the disgrace of Nazi eugenic policies to alter attitudes. The period 1945 to 1974, the Baby scoop
era, saw rapid growth and acceptance of adoption as a means to build a family.[40] Illegitimate births rose three-fold
after World War II, as sexual mores changed. Simultaneously, the scientific community began to stress the
dominance of nurture over genetics, chipping away at eugenic stigmas.[41] [42] In this environment, adoption became
the obvious solution for both unwed mothers and infertile couples.[43]
Taken together, these trends resulted in a new American model for adoption. Following its Roman predecessor,
Americans severed the rights of the original parents while making adopters the new parents in the eyes of the law.
Two innovations were added: 1) adoption was meant to ensure the "best interests of the child;" the seeds of this idea
can be traced to the first American adoption law in Massachusetts,[16] [23] and 2) adoption became infused with
secrecy, eventually resulting in the sealing of adoption and original birth records by 1945. The origin of the move
toward secrecy began with Charles Loring Brace who introduced it to prevent children from the Orphan Trains from
returning to or being reclaimed by their parents. Brace feared the impact of the parents' poverty, in general, and their
Catholic religion, in particular, on the youth. This tradition of secrecy was carried on by the later Progressive
reformers when drafting of American laws.[44]
The number of adoptions in the United States peaked in 1970.[45] It is uncertain what caused the subsequent decline.
Likely contributing factors in the 1960s and 1970s include a decline in the fertility rate, associated with the
introduction of the pill, the completion of legalization of artificial birth control methods, the introduction of federal
funding to make family planning services available to the young and low income, and the legalization of abortion. In
addition, the years of the late 1960s and early 1970s saw a dramatic change in society's view of illegitimacy and in
Adoption
the legal rights[46] of those born outside of wedlock. In response, family preservation efforts grew[47] so that few
children born out of wedlock today are adopted (Refer to Table 1). Ironically, adoption is far more visible and
discussed in society today, yet it is less common.[48]
Race
Before 1973
19731981 19821988 19891995 19962002
8.7%
4.1%
2.0%
0.9%
1.0%
Black Women 1.5%
0.2%
1.1%
0.0%
NA
White Women 19.3%
7.5%
3.2%
1.7%
1.3%
All Women
Table 1: Percentage of Infants (Born to Never-Married Women) Who Were Relinquished[49]

The American model of adoption eventually proliferated globally. England and Wales established their first formal
adoption law in 1926. The Netherlands passed its law in 1956. Sweden made adoptees full members of the family in
1959. West Germany enacted its first laws in 1977.[50] Additionally, the Asian powers opened their orphanage
systems to adoption, influenced as they were by Western ideas following colonial rule and military occupation.[51]
Although adoption is today practiced globally, the United States remains the leader in its use. The table below
provides a snapshot of Western adoption rates. Adoption in the United States still occurs at nearly three times those
of its peers although the number of children awaiting adoption has held steady in recent years, hovering between
133,000 to 129,000 during the period 2002 to 2006.[52]
Country
Adoptions
Live Births
[53]
Australia
270 (20072008)
England &
Wales
4,764 (2006)
Iceland
between 20-35
[57]
year
Ireland
263 (2003)
Italy
3,158 (2006)
Norway
657 (2006)
Sweden
1044(2002)
[55]
[59]
[61]
[63]
[65]
United States approx 127,000

[67]
(2001)
Adoption/Live Birth
Ratio
Notes
[54] 0.2 per 100 Live

Births
Includes known relative adoptions
[56]
Includes all adoption orders in England and Wales
254,000 (2004)
669,601(2006)
[58]
4,560 (2007)
[60]
61,517 (2003)
0.7 per 100 Live

Births
0.8 per 100 Live
Births
0.4 per 100 Live
Births
92 non-family adoptions; 171 family adoptions (e.g.

stepparent). 459 international adoptions were also recorded.
[62] 0.6 per 100 Live

Births
560,010 (2006)
[64]
1.1 per 100 Live

Births
Adoptions breakdown: 438 inter-country; 174 stepchildren; 35

foster; 10 other.
91,466(2002)
[66]
1.1 per 100 Live

Births
10-20 of these were national adoptions of infants. The rest

were international adoptions.
4,021,725
[68]
(2002)
~3 per 100 Live

Births
The number of adoptions is reported to be constant since 1987.
58,545(2006)
Table 2: Adoptions, Live Births, and Adoption/Live Birth Ratios are provided in the table below (alphabetical, by
country) for a number of Western countries
Adoption
Contemporary adoption
Forms of adoption
Contemporary adoption practices can be open or closed.
Open adoption allows identifying information to be communicated between adoptive and biological parents and,
perhaps, interaction between kin and the adopted person. Rarely, it is the outgrowth of laws that maintain an
adoptee's right to unaltered birth certificates and/or adoption records, but such access is not universal (it is
possible in a few jurisdictions - including the U.K. and six States in the U.S.).[69] [69] [70] [71] [72] Open adoption
can be an informal arrangement subject to termination by adoptive parents who have sole authority over the child.
In some jurisdictions, the biological and adoptive parents may enter into a legally-enforceable and binding
agreement concerning visitation, exchange of information, or other interaction regarding the child.[73] As of
February 2009, 24 U.S. states allowed legally enforceable open adoption contract agreements to be included in
the adoption finalization.[74]
The practice of closed adoption, the norm for most of modern history,[75] seals all identifying information,
maintaining it as secret and barring disclosure of the adoptive parents', biological kins', and adoptees' identities.
Nevertheless, closed adoption may allow the transmittal of non-identifying information such as medical history
and religious and ethnic background.[76] Today, as a result of safe haven laws passed by some U.S. states, closed
adoption is seeing renewed influence. In safe-haven states, infants can be left, anonymously, at hospitals, fire
departments, or police stations within a few days of birth, a practice criticized by some adoptee advocacy
organizations as being retrograde and dangerous.[77]
How adoptions originate

Adoptions can occur either between related family members, or
unrelated individuals. Historically, most adoptions occurred within a
family. The most recent data from the U.S. indicates about half of
adoptions are currently between related individuals.[78] A common
example of this is a "stepparent adoption", where the new partner of a
parent may legally adopt a child from the parent's previous
relationship. Intra-family adoption can also occur through surrender, as
a result of parental death, or when the child cannot otherwise be cared
for and a family member agrees to take over.
The New York Foundling Home is among North
Infertility is the main reason parents seek to adopt children they are not
America's oldest adoption agencies.
related to. One study shows this accounted for 80% of unrelated infant
adoptions and half of adoptions through foster care.[79] Estimates suggest that 1124% of Americans who cannot
conceive or carry to term attempt to build a family through adoption, and that the overall rate of ever-married
American women who adopt is about 1.4%.[80] [81] Other reasons people adopt are numerous although not well
documented. These may include wanting to cement a new family following divorce or death of one parent,
compassion motivated by religious or philosophical conviction, to avoid contributing to perceived overpopulation
out of the belief that it is more responsible to care for otherwise parent-less children than to reproduce, to ensure that
inheritable diseases (e.g., Tay-Sachs disease) are not passed on, and health concerns relating to pregnancy and
childbirth. Although there are a range of possible reasons, the most recent study of experiences of women who adopt
suggests they are most likely to be 4044 years of age, currently married, have impaired fertility, and childless.[82]
Unrelated adoptions may occur through the following mechanisms:
Private domestic adoptions: under this arrangement, charities and for-profit organizations act as intermediaries,
bringing together prospective adoptive parents and families who want to place a child, all parties being residents
Adoption
of the same country. Alternatively, prospective adoptive parents sometimes avoid intermediaries and connect with
women directly, drafting contracts through a lawyer (these efforts are illegal in some jurisdictions). Private
domestic adoption accounts for a significant portion of all adoptions; in the United States, for example, nearly
45% of adoptions are estimated to have occurred through private arrangements.[83]
Foster care adoption: this is a type of domestic adoption where a child is initially placed in public care. Its
importance as an avenue for adoption varies by country. Nevertheless, the example of the United States is
instructive. Of the 127,500 adoptions that occurred in the U.S.[83] about 51,000 or 40% were through the foster
care system.[84]
International adoption: involves the placing of a child for adoption outside that childs country of birth. This can
occur through both public and private agencies. In some countries, such as Sweden, these adoptions account for
the majority of cases (see above Table). The U.S. example, however, indicates there is wide variation by country
since adoptions from abroad account for less than 15% of its cases.[83] More than 60,000 Russian children have
been adopted in the United States since 1992,[85] and between 1995 and 2005, Americans adopted more than
60,000 children from China.[86] The laws of different countries vary in their willingness to allow international
adoptions. Recognizing the difficulties and challenges associated with international adoption, and in an effort to
protect those involved from the corruption and exploitation which sometimes accompanies it, the Hague
Conference on Private International Law developed the [Hague Adoption Convention], which came into force on
1 May 1995 and has been ratified by 85 countries as of November 2011.[87]
Embryo adoption: based on the donation of embryos remaining after one couples in vitro fertilization treatments
have been completed; embryos are given to another individual or couple, followed by the placement of those
embryos into the recipient womans uterus, to facilitate pregnancy and childbirth. In the United States, embryo
adoption is governed by property law rather than by the court systems, in contrast to traditional adoption.
Common law adoption: this is an adoption which has not been recognized beforehand by the courts, but where a
parent, without resort to any formal legal process, leaves his or her children with a friend or relative for an
extended period of time.[88] [89] At the end of a designated term of (voluntary) co-habitation, as witnessed by the
public, the adoption is then considered binding, in some courts of law, even though not initially sanctioned by the
court. The particular terms of a common-law adoption are defined by each legal jurisdiction. For example, the
U.S. state of California recognizes common law relationships after co-habitation of 2 years. The practice is called
"private fostering" in Britain.[90]
How adoptions can disrupt

Disruption refers to the termination of an adoption. This includes adoptions that end prior to legal finalization and
those that end after that point (in U.S. law, the latter cases are referred to as having been dissolved). The Disruption
process is usually initiated by adoptive parents via a court petition and is analogous to divorce proceedings. It is a
legal avenue unique to adoptive parents as disruption/dissolution does not apply to biological kin.[91]
Ad hoc studies, performed in the U.S., however, suggest that between 10-25 percent of adoptions disrupt before they
are legally finalized and from 1-10 percent are dissolved after legal finalization. The wide range of values reflects the
paucity of information on the subject and demographic factors such as age; it is known that older children are more
prone to having their adoptions disrupted.[91]
Adoption
Parenting and development of adoptees

Parenting
Biological ties are the hallmark of parent-child relationships, and its absence has caused concern throughout the
history of adoption. The traditional concern is expressed by Jessie Taft, a pioneer in the professionalization of
adoption services and herself an adoptive mother, who commented on her contemporaries' view of adoptive
parenting, "No one who is not willfully deluded would maintain that the experiences of adoption can take the place
of the actual bearing and rearing of an own child."[92]
The traditional view of adoptive parenting received empirical support from a Princeton University study of 6,000
adoptive, step, and foster families in the United States and South Africa from 19681985; the study indicated that
food expenditures in households with mothers of non-biological children (when controlled for income, household
size, hours worked, age, etc.) were significantly less for adoptees, step-children, and foster children, causing the
researchers to speculate that, instinctually, people are less interested in sustaining the genetic lines of others.[93] This
theory is supported in another more qualitative study where in adoptive relationships marked by sameness in likes,
personality, and appearance, both adult adoptees and adoptive parents report being happier with the adoption.[94]
Other studies provide evidence that adoptive relationships can form along other lines. A study evaluating the level of
parental investment indicates strength in adoptive families, suggesting that parents who adopt invest more time in
their children than other parents and concludes, "...adoptive parents enrich their children's lives to compensate for the
lack of biological ties and the extra challenges of adoption."[95] Another recent study found that adoptive families
invested more heavily in their adopted children, for example, by providing further education and financial support.
Noting that adoptees seemed to be more likely to experience problems such as drug addiction, the study speculated
that adoptive parents might invest more in adoptees not because they favor them, but because they are more likely
than genetic children to need the help.[96]
Beyond the foundational issues, the unique questions posed for adoptive parents are varied. They include how to
respond to stereotypes, answering questions about heritage, and how best to maintain connections with biological kin
when in an open adoption.[97] One author suggests a common question adoptive parents have is: "Will we love the
child even though he/she is not our biological child?"[98] A specific concern for many parents is accommodating an
adoptee in the classroom.[99] Familiar lessons like "draw your family tree" or "trace your eye color back through
your parents and grandparents to see where your genes come from" could be hurtful to children who were adopted
and do not know this biological information. Numerous suggestions have been made to substitute new lessons, e.g.,
focusing on "family orchards."[100]
Adopting older children presents other parenting issues. Some children from foster care have histories of
maltreatment, such as physical and psychological neglect, physical abuse, and sexual abuse, are at risk of developing
psychiatric problems.[101] [102] Such children are at risk of developing a disorganized attachment.[103] [104] [105]
Studies by Cicchetti et al. (1990, 1995) found that 80% of abused and maltreated infants in their sample exhibited
disorganized attachment styles.[106] [107] Disorganized attachment is associated with a number of developmental
problems, including dissociative symptoms,[108] as well as depressive, anxiety, and acting-out symptoms.[109] [110]
Development
The consensus among researchers is that adoption affects development throughout life, with the fact of "being
adopted," creating unique responses to significant life-events, e.g., the birth of a child. As a result, researchers often
assume that the adoptee population faces heightened risk in terms of psychological development and social
relationships. Earlier literature on the topic supported the conception of such problems, however, much of that
research has since been deemed flawed due to methodological failures.[111]
Some conclusions about the development of adoptees can be gleaned from newer studies, though, and it can be said
that adoptees, in some respect, seem to develop differently than the general population while facing greater risks
Adoption
during adolescence. Many adopted persons experience difficulty in establishing a sense of identity.[112]
Concerning developmental milestones, studies from the Colorado Adoption Project examined genetic influences on
adoptee maturation, concluding that cognitive abilities of adoptees reflect those of their adoptive parents in early
childhood but show little similarity by adolescence, resembling instead those of their biological parents and to the
same extent as peers in non-adoptive families.[113]
Similar mechanisms appear to be at work in the physical development of adoptees. Danish and American researchers
conducting studies on the genetic contribution to body mass index found correlations between an adoptee's weight
class and his biological parents' BMI while finding no relationship with the adoptive family environment. Moreover,
about one-half of inter-individual differences were due to individual non-shared influences.[114] [115]
These differences in development appear to play out in the way young adoptees deal with major life events. In the
case of parental divorce, adoptees have been found to respond differently than children who have not been adopted.
While the general population experienced more behavioral problems, substance use, lower school achievement, and
impaired social competence after parental divorce, the adoptee population appeared to be unaffected in terms of their
outside relationships, specifically in their school or social abilities.[116]
The adoptee population does, however, seem to be more at risk for certain behavioral issues. Researchers from the
University of Minnesota studied adolescents who had been adopted and found that adoptees were twice as likely as
non-adopted people to suffer from oppositional defiant disorder and attention-deficit/hyperactivity disorder (with an
8% rate in the general population).[117] Suicide risks were also significantly greater than the general population.
Swedish researchers found both international and domestic adoptees undertook suicide at much higher rates than
non-adopted peers; with international adoptees and female international adoptees, in particular, at highest risk.[118]
Nevertheless, work on adult adoptees has found that the additional risks faced by adoptees are largely confined to
adolescence. Young adult adoptees were shown to be alike with adults from biological families and scored better
than adults raised in alternative family types including single parent and step-families.[119] Moreover, while adult
adoptees showed more variability than their non-adopted peers on a range of psychosocial measures, adult adoptees
exhibited more similarities than differences with adults who had not been adopted.[120] There have been many cases
of remediation or the reversibility of early trauma. For example, in one of the earliest studies conducted, Professor
Goldfarb in England concluded that some children adjust well socially and emotionally despite their negative
experiences of institutional deprivation in early childhood.[121] Other researchers also found that prolonged
institutionalization does not necessarily lead to emotional problems or character defects in all children. This suggests
that there will always be some children who fare well, who are resilient, regardless of their experiences in early
childhood. [122]
Adoption
10
Public perception of adoption

In Western culture, the dominant conception of
family revolves around a heterosexual couple
with biological offspring. This idea places
alternative family forms outside the norm. As a
consequence, research indicates, disparaging
views of adoptive families exist, along with
doubts concerning the strength of their family
bonds.[123] [124]
The most recent adoption attitudes survey
completed by the Evan Donaldson Institute
provides further evidence of this stigma. Nearly
one-third of the surveyed population believed
adoptees are less-well adjusted, more prone to
Actors at the Anne of Green Gables Museum on Prince Edward Island,
medical issues, and predisposed to drug and
Canada. Since its first publication in 1908, the story of the orphaned Anne,
alcohol problems. Additionally, 40-45% thought
and how the Cuthberts took her in, has been widely popular in the
adoptees were more likely to have behavior
English-speaking world and, later, Japan.
problems and trouble at school. In contrast, the
same study indicated adoptive parents were viewed favorably, with nearly 90% describing them as, "lucky,
advantaged, and unselfish."[125]
The majority of people state that their primary source of information about adoption comes from friends and family
and the news media. Nevertheless, most people report the media provides them a favorable view of adoption; 72%
indicated receiving positive impressions.[126] There is, however, still substantial criticism of the media's adoption
coverage. Some adoption blogs, for example, criticized Meet the Robinsons for using outdated orphanage
imagery[127] [128] as did advocacy non-profit The Evan B. Donaldson Adoption Institute.[129]
The stigmas associated with adoption are amplified for children in foster care.[130] Negative perceptions result in the
belief that such children are so troubled it would be impossible to adopt them and create "normal" families.[131] A
2004 report from the Pew Commission on Children in Foster Care has shown that the number of children waiting in
foster care doubled since the 1980s and now remains steady at about a half-million a year."[132]
Adoption
Reform and reunion trends

Adoption practices have significantly changed over the course of the last century,
with each new movement labeled, in some way, as reform.[133] Beginning in the
1970s efforts to improve adoption became associated with opening records and
encouraging family preservation. These ideas arose from suggestions that the
secrecy inherent in modern adoption may influence the process of forming an
identity,[134] [135] create confusion regarding genealogy,[136] and provide little in
the way of medical history.
Family preservation: As concerns over illegitimacy began to decline in the
early 1970s, social-welfare agencies began to emphasize that, if possible,
mothers and children should be kept together.[137] In America, this was clearly
illustrated by the shift in policy of the New York Foundling Home, an
Open Records emblem used in
adoption-institution that is among the country's oldest and one that had pioneered
Adoptee Rights Protest, New
sealed records. It established three new principles including, "to prevent
Orleans, 2008, artist: D. Martin.
placements of children...," reflecting the belief that children would be better
served by staying in their own families and communities, a striking shift in policy that remains in force today.[138]
Open records: Movements to unseal adoption records for adopted citizen proliferated along with increased
acceptance of illegitimacy. In the United States, Jean Paton founded Orphan Voyage in 1954, Florence Fisher the
Adoptees' Liberty Movement Association (ALMA) in 1971, calling sealed records "an affront to human
dignity.".[139] While in 1975, Emma May Vilardi created the first mutual-consent registry, the International Soundex
Reunion Registry (ISRR), allowing those separated by adoption to locate one another.[140] and Lee Campbell and
other birthmothers established CUB Concerned United Birthparents. Similar ideas were taking hold globally with
grass-roots organizations like Parent Finders in Canada and Jigsaw in Australia. In 1975, England and Wales opened
records on moral grounds.[141]
By 1979, representatives of 32 organizations from 33 states, Canada and Mexico gathered in Washington, DC to
establish the American Adoption Congress (AAC) passing a unanimous resolution: "Open Records complete with all
identifying information for all members of the adoption triad, birthparents, adoptive parents and adoptee at the
adoptee's age of majority or earlier if all members of the triad agree." [142] Later years saw the evolution of more
militant organizations such as Bastard Nation (founded in 1996), groups that helped overturn sealed records in
Alabama, Delaware, New Hampshire, Oregon, Tennessee, and Maine.[143] [144] Simultaneously, groups such as
Origins USA (founded in 1997) started to actively speak about family preservation and the rights of mothers.[145]
The intellectual tone of these recent reform movements was influenced by the publishing of The Primal Wound by
Nancy Verrier. "Primal wound" is described as the "devastation which the infant feels because of separation from its
birth mother. It is the deep and consequential feeling of abandonment which the baby adoptee feels after the adoption
and which may continue for the rest of his life."[134]
11
Adoption
12
Reunion
Estimates for the extent of search behavior by adoptees have proven
elusive; studies show significant variation.[146] In part, the problem
stems from the small adoptee population which makes random
surveying difficult, if not impossible.
Writer Lesley Lathrop (left), an adoptee, at

reunion
Nevertheless, some indication of the level of search interest by

adoptees can be gleaned from the case of England and Wales which
opened adoptees' birth records in 1975. The UK Office for National
Statistics has projected that 33% of all adoptees would eventually
request a copy of their original birth records, exceeding original
forecasts made in 1975 when it was believed that only a small fraction
of the adoptee population would request their records. The projection is
known to underestimate the true search rate, however, since many
adoptees of the era have access to get their information by other
means.[147]
The research literature states adoptees give four reasons for desiring reunion: 1) they wish for a more complete
genealogy, 2) they are curious about events leading to their conception, birth, and relinquishment, 3) they hope to
pass on information to their children, and 4) they have a need for a detailed biological background, including
medical information. It is speculated by adoption researchers, however, that the reasons given are incomplete:
although such information could be communicated by a third-party, interviews with adoptees, who sought reunion,
found they expressed a need to actually meet biological relations.[148]
It appears the desire for reunion is linked to the adoptee's interaction with and acceptance within the community.
Internally-focused theories suggest some adoptees possess ambiguities in their sense of self, impairing their ability to
present a consistent identity. Reunion helps resolve the lack of self-knowledge.[149]
Externally-focused theories, in contrast, suggest that reunion is a way for adoptees to overcome social stigma. First
proposed by Goffman, the theory has four parts: 1) adoptees perceive the absence of biological ties as distinguishing
their adoptive family from others, 2) this understanding is strengthened by experiences where non-adoptees suggest
adoptive ties are weaker than blood ties, 3) together, these factors engender, in some adoptees, a sense of social
exclusion, and 4) these adoptees react by searching for a blood tie that reinforces their membership in the
community. The externally-focused rationale for reunion suggests adoptees may be well adjusted and happy within
their adoptive families, but will search as an attempt to resolve experiences of social stigma.[150]
Some adoptees reject the idea of reunion. It is unclear, though, what differentiates adoptees who search from those
who do not. One paper summarizes the research, stating, "attempts to draw distinctions between the searcher and
non-searcher are no more conclusive or generalizable than attempts to substantiatedifferences between adoptees
and nonadoptees."[151]
In sum, reunions can bring a variety of issues for adoptees and parents. Nevertheless, most reunion results appear to
be positive. In the largest study to date (based on the responses of 1,007 adoptees and relinquishing parents), 90%
responded that reunion was a beneficial experience. This does not, however, imply ongoing relationships were
formed between adoptee and parent nor that this was the goal.[152]
The book "Adoption Detective: Memoir of an Adopted Child" by Judith and Martin Land provides provides insight
into the mind of an adoptee from childhood through to adulthood and the emotions invoked when reunification with
their birth mothers is desired.
Adoption
Controversial adoption practices

Reform and family preservation efforts have also been strongly associated with the perceived mis-use of adoption. In
some cases, parents' rights have been terminated when their ethnic or socio-economic group has been deemed unfit
by society.
Forced adoption based on ethnicity occurred during World War II. In German occupied Poland, it is estimated that
200,000 Polish children with purportedly Aryan traits were removed from their families and given to German or
Austrian couples,[153] and only 25,000 returned to their families after the war.[154]
The Stolen Generation of Aboriginal people in Australia were affected by similar policies, as were Native Americans
in the United States and First Nations of Canada. These practices have become significant social and political issues
in recent years, and many cases the policies have changed. The United States, for example, now has the 1978 Indian
Child Welfare Act, which allows the tribe and family of a Native American child to be involved in adoption
decisions, with preference being given to adoption within the child's tribe.[155]
From the 1950s through the 1970s, a period called the Baby scoop era, adoption practices that involved coercion
were directed against unwed mothers, as detailed in The Girls Who Went Away.
Adoption terminology
The language of adoption is changing and evolving, and since the 1970s has been a controversial issue tied closely
to adoption reform efforts. The controversy arises over the use of terms which, while designed to be more appealing
or less offensive to some persons affected by adoption, may simultaneously cause offense or insult to others. This
controversy illustrates the problems in adoption, as well as the fact that coining new words and phrases to describe
ancient social practices will not necessarily alter the feelings and experiences of those affected by them. Two of the
contrasting sets of terms are commonly referred to as positive adoption language (PAL) (sometimes called
respectful adoption language (RAL)), and honest adoption language (HAL).
Positive Adoptive Language (PAL)
In the 1970s, as adoption search and support organizations developed, there were challenges to the language in
common use at the time. As books like Adoption Triangle by Sorosky, Pannor and Baran were published, and
support groups formed like CUB (Concerned United Birthparents), a major shift from natural parent to birthparent
[156] [157]
occurred. Along with the change in times and social attitudes came additional examination of the language
used in adoption.
Social workers and other professionals in the field of adoption began changing terms of use to reflect what was being
expressed by the parties involved. In 1979, Marietta Spencer wrote "The Terminology of Adoption" for The Child
Welfare League of America (CWLA),[158] which was the basis for her later work "Constructive Adoption
Terminology".[159] This influenced Pat Johnston's "Positive Adoption Language" (PAL) and "Respectful Adoption
Language" (RAL).[160] The terms contained in "Positive Adoption Language" include the terms "birth mother" (to
replace the terms "natural mother" and "real mother"), "placing" (to replace the term "surrender"). These kinds of
recommendations were an attempt to encourage people to be more aware of their terminology.
Honest Adoption Language (HAL)
"Honest Adoption Language" refers to a set of terms that proponents say reflect the point of view that: (1) family
relationships (social, emotional, psychological or physical) that existed prior to the legal adoption often continue past
this point or endure in some form despite long periods of separation, and that (2) mothers who have "voluntarily
surrendered" children to adoption (as opposed to involuntary terminations through court-authorized child-welfare
proceedings) seldom view it as a choice that was freely made, but instead describe scenarios of powerlessness, lack
of resources, and overall lack of choice.[161] [162] It also reflects the point of view that the term "birth mother" is
derogatory in implying that the woman has ceased being a mother after the physical act of giving birth. Proponents
13
Adoption
of HAL liken this to the mother being treated as a "breeder" or "incubator".[163] Terms included in HAL include
terms that were used before PAL, including "natural mother," "first mother," and "surrendered for adoption."
Inclusive Adoption Language
There are supporters of various lists, developed over many decades, and there are persons who find them lacking,
created to support an agenda, or furthering division. All terminology can be used to demean or diminish, uplift or
embrace. In addressing the linguistic problem of naming, Edna Andrews says that using "inclusive" and "neutral"
language is based upon the concept that "language represents thought, and may even control thought."[164]
Advocates of inclusive language defend it as inoffensive-language usage whose goal is multi-fold:
1. The rights, opportunities, and freedoms of certain people are restricted because they are reduced to stereotypes.
2. Stereotyping is mostly implicit, unconscious, and facilitated by the availability of pejorative labels and terms.
3. Rendering the labels and terms socially unacceptable, people then must consciously think about how they
describe someone unlike themselves.
4. When labeling is a conscious activity, the described person's individual merits become apparent, rather than his or
her stereotype.
A common problem is that terms chosen by an identity group, as acceptable descriptors of themselves, can be used in
negative ways by detractors. This compromises the integrity of the language and turns what was intended to be
positive into negative or vice-versa, thus often devaluing acceptability, meaning and use.
Language at its best honors the self-referencing choices of the persons involved, utilizes inclusive terms and phrases,
and is sensitive to the feelings of the primary parties. Language evolves with social attitudes and experiences.[165]
[166]
Cultural variations
Attitudes and laws regarding adoption vary greatly. Whereas all cultures make arrangements whereby children
whose own parents are unavailable to rear them can be brought up by others, not all cultures have the concept of
adoption, that is treating unrelated children as equivalent to biological children of the adoptive parents. Under
Islamic Law, for example, adopted children must keep their original surname to be identified with blood
relations,[167] and, traditionally, observe hijab (the covering of women in the presence of non-family) in their
adoptive households. In Egypt, these cultural distinctions have led to making adoption illegal.[168]
Further reading
Christine Ward Gailey. Blue-Ribbon Babies and Labors of Love: Race, Class, and Gender in U.S. Adoption
Practice (University of Texas Press; 185 pages; 2010). Uses interviews with 131 adoptive parents in a study of
how adopters' attitudes uphold, accommodate, or subvert prevailing ideologies of kinship in the United States.
Pertman, A. (2000). Adoption Nation: How the Adoption Revolution Is Transforming America. New York: Basic
Books.
14
Adoption
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15
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[101] Gauthier, L., Stollak, G., Messe, L., & Arnoff, J. (1996). Recall of childhood neglect and physical abuse as differential predictors of current
psychological functioning. Child Abuse and Neglect 20, 549-559
[102] Malinosky-Rummell, R. & Hansen, D.J. (1993) Long term consequences of childhood physical abuse. Psychological Bulletin 114, 68-69
[103] Lyons-Ruth K. & Jacobvitz, D. (1999) Attachment disorganization: unresolved loss, relational violence and lapses in behavioral and
attentional strategies. In J. Cassidy & P. Shaver (Eds.) Handbook of Attachment. (pp. 520-554). NY: Guilford Press
[104] Solomon, J. & George, C. (Eds.) (1999). Attachment Disorganization. NY: Guilford Press
[105] Main, M. & Hesse, E. (1990) Parents Unresolved Traumatic Experiences are related to infant disorganized attachment status. In M.T.
Greenberg, D. Ciccehetti, & E.M. Cummings (Eds), Attachment in the Preschool Years: Theory, Research, and Intervention (pp161-184).
Chicago: University of Chicago Press
[106] Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1995). Finding order in disorganization: Lessons from research on maltreated
infants attachments to their caregivers. In D. Cicchetti & V. Carlson (Eds), Child Maltreatment: Theory and research on the causes and
consequences of child abuse and neglect (pp. 135-157). NY: Cambridge University Press.
[107] Cicchetti, D., Cummings, E.M., Greenberg, M.T., & Marvin, R.S. (1990). An organizational perspective on attachment beyond infancy. In
M. Greenberg, D. Cicchetti, & M. Cummings (Eds), Attachment in the Preschool Years (pp. 3-50). Chicago: University of Chicago Press.
[108] Carlson, E.A. (1988). A prospective longitudinal study of disorganized/disoriented attachment. Child Development 69, 1107-1128
[109] Lyons-Ruth, K. (1996). Attachment relationships among children with aggressive behavior problems: The role of disorganized early
attachment patterns. Journal of Consulting and Clinical Psychology 64, 64-73
[110] Lyons-Ruth, K., Alpern, L., & Repacholi, B. (1993). Disorganized infant attachment classification and maternal psychosocial problems as
predictors of hostile-aggressive behavior in the preschool classroom. Child Development 64, 572-585
[111] L. Borders, et. Adult Adoptees and Their Friends, National Council of Family Relations, 2000, Vol. 49, No. 4,
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[112] Beauchesne, Lise M. (1997). [http://scholars.wlu.ca/etd/213/ As if born to: The social construction of a deficit identity position for adopted
persons (D.S.W. dissertation) Wilfrid Laurier University
[113] Plomin, R., Fulker, D.W., Corley, R., & DeFries, J.C. (1997). Nature, nurture, and cognitive development from 1-16 years: A
parent-offspring adoption study. Psychological Science, 8, 442-447.
[114] AJ Stunkard, An adoption study of human obesity, The New England Journal of Medicine (http:/ / content. nejm. org/ cgi/ content/
abstract/ 314/ 4/ 193) Volume 314:193-198, January 23, 1986
[115] Vogler, G.P., Influences of genes and shared family environment on adult body mass index assessed in an adoption study by a
comprehensive path model, International journal of obesity (http:/ / cat. inist. fr/ ?aModele=afficheN& cpsidt=3406929), 1995, vol. 19, no1,
pp. 40-45
[116] Thomas OConner, Are Associations Between Parental Divorce and Childrens Adjustment Genetically Mediated?, American
Psychological Association (http:/ / www. apa. org/ journals/ features/ dev364429. pdf) 2000, Vol. 36 No.4 429-437
[117] Kaplan, Arline, Psychiatric Times (http:/ / www. psychiatrictimes. com/ display/ article/ 10168/ 1367897), January 26, 2009
[118] Annika von Borczyskowski, Suicidal behavior in national and international adult adoptees, Social Psychiatry and Psychiatric Epidemiology
(http:/ / www. springerlink. com/ content/ y73646n507593n76/ ) Volume 41, Number 2 / February, 2006
[119] William Feigelman, Comparisons with Persons Raised in Conventional Families, Marriage & Family Review, 1540-9635, Volume 25,
Issue 3, 1997, Pages 199 223
[120] L. DiAnne Border, Adult Adoptees and Their Friends, [[Family Relations (journal)|Family Relations (http:/ / www. jstor. org/ pss/
585836)]] 2000, 49, 407-418
[121] Goldfarb, W. (1955). Emotional and intellectual consequences of psychologic deprivation in infancy: A Re-evaluation. In P. Hoch & J.
Zubin (Eds.), Psychopathology of Childhood (pp. 105-119). NY: Grune & Stratton.
[122] Pringel, M. L., & Bossio, V. (1960). Early, prolonged separation and emotional adjustment. Journal of Child Psychology and Psychiatry,
37-48
[123] http:/ / www. jstor. org/ pss/ 585831 Katrina Wegar, Adoption, Family Ideology, and Social Stigma: Bias in Community Attitudes,
Adoption Research, and Practice, Family Relations, Vol. 49, No. 4 (Oct., 2000), pp. 363-370.
[124] http:/ / www. jstor. org/ pss/ 353920 K. March, Journal of Marriage and the Family 57 August 1995: pg. 654.
[125] National Adoption Attitudes Survey, June 2002, Evan Donaldson Institute, page 20 and 38."
[126] National Adoption Attitudes Survey, June 2002, Evan Donaldson Institute, page 47
[127] 3 Generations of Adoption, April 12, 2007 (http:/ / adopteesx3. blogspot. com/ 2007/ 04/ usa-today-article-on-meet-robinsons. html)
[128] Maya's Mom,, April 7, 2007 (http:/ / www. mayasmom. com/ talk/ a8739/ meet_the_robinsons)
[129] The Evan B. Donaldson Adoption Institute, April 9, 2007 press release (http:/ / www. adoptioninstitute. org/ media/
20070409_press_disney. php)
[130] National Adoption Attitudes Survey, June 2002, Evan Donaldson Institute, page 20.
[131] http:/ / www. adoptioninstitute. org/ policy/ polface. html The Evan B. Donaldson Adoption Institute
[132] http:/ / pewfostercare. org/ docs/ index. php?DocID=41 The Pew Commission of Children in Foster Care
[133] Adoption History Project (University of Oregon), Topic History in Brief (http:/ / darkwing. uoregon. edu/ ~adoption/ topics/
adoptionhistbrief. htm)
[134] Book Review: The Primal Wound by Nancy N. Verrier (http:/ / primal-page. com/ verrier. htm)
[135] Miles, 2003: Does Adoption Affect the Adolescent Eriksonian Task of Identity Formation? Available: http:/ / www. cs. brown. edu/
~jadrian/ docs/ papers/ old/ 20030212%20Miles%20-%20Adoptive%20Identity. pdf Retrieved: 30 Jan, 2008
[136] http:/ / www. bastards. org/ activism/ support. htm Why Adoptive Parents Support Open Records for Adult Adoptees
[137] Adoption History Project (University of Oregon), Topic Illegtimacy (http:/ / darkwing. uoregon. edu/ ~adoption/ topics/ illegitimacy. htm)
[138] Martin Gottlieb, The Foundling, 2001, pg. 105-106
[139] Adoption History Project Topic Confidentiality (http:/ / darkwing. uoregon. edu/ ~adoption/ topics/ confidentiality. htm)
[140] ISRR - International Soundex Reunion Registry Reunion Registry (http:/ / www. isrr. net/ history. html)
[141] R. Rushbrooke, The proportion of adoptees who have received their birth records in England and Wales, Population Trends (104), Summer
2001, pp 26-34.
[142] TRIADOPTION Archives TRIADOPTION Archives (http:/ / www. triadoption. com/ Misc/ AAC 1979 Resolution. pdf)
[143] USA Today, As adoptees seek roots, states unsealing records (http:/ / www. usatoday. com/ printedition/ news/ 20080213/ 1a_adoptionxx.
art. htm), 2/13/2008.
[144] Bastard Nation, BASTARD NATION - New Hampshire (http:/ / www. bastards. org/ activism/ local/ nh/ )
[145] Origins USA position papers Available: http:/ / originsusa. memberlodge. org/ Default. aspx?pageId=24588 Accessed: 27th April 2008.
[146] Schechter and Bertocci, The Meaning of the Search in Brodzinsky and Schechter, Psychology of Adoption, 1990, pg. 67
[147] R. Rushbrooke, The proportion of adoptees who have received their birth records in England and Wales, Population Trends (104), UK
Office for National Statistics, Summer 2001, pages 26-34
[148] http:/ / www. jstor. org/ pss/ 353920 K. March, Journal of Marriage and the Family 57 August 1995: pg. 653-660
[149] http:/ / digitalcommons. mcmaster. ca/ dissertations/ AAINN60675/ K. March, The stranger who bore me: Adoptee-birth mother
interactions, Dissertation, McMaster University, 1990
[150] http:/ / www. jstor. org/ pss/ 353920 K. March, Journal of Marriage and the Family 57 August 1995: pg. 653-660.
[151] Schechter and Bertocci, The Meaning of the Search in Brodzinsky and Schechter, Psychology of Adoption, 1990, pg. 70
18
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[152] R. Sullivan and E. Lathrop, Openness in adoption: retrospective lessons and prospective choices, Children and Youth Services Review
Vol. 26 Issue 4, April 2004.
[153] " Searching for missing relatives in Poland (http:/ / www. ft. com/ cms/ s/ 2/ edf71f50-c208-11de-be3a-00144feab49a. html)". Financial
Times. October 30, 2009.
[154] Gitta Sereny, "Stolen Children" (http:/ / www. jewishvirtuallibrary. org/ jsource/ Holocaust/ children. html), rpt. in Jewish Virtual Library
(American-Israeli Cooperative Enterprise). Accessed September 15, 2008.
[155] National Indian Child Welfare Association: the Indian Child Welfare Act of 1978 (ICWA) (http:/ / www. nicwa. org/
Indian_Child_Welfare_Act/ )
[156] Birthparent Legacy Term (http:/ / www. sacredhealing. com/ triadoption/ Misc. / Origin of the Term Birthparent. pdf) TRIADOPTION
Archives
[157] Birth Parents (http:/ / darkwing. uoregon. edu/ ~adoption/ topics/ birthparents. htm) The Adoption History Project
[158] Adoption Terminology (http:/ / darkwing. uoregon. edu/ ~adoption/ archive/ CwlaAT. htm) Child Welfare League of American 1980s
[159] Adoption Language (http:/ / library. adoption. com/ articles/ a-few-words-on-words-in-adoption. html) by Brenda Romanchik
[160] Speaking Positively: Using Respectful Adoption Language (http:/ / www. perspectivespress. com/ pjpal. html), by Patricia Irwin Johnston
[161] Logan, J. (1996). "Birth Mothers and Their Mental Health: Uncharted Territory". British Journal of Social Work 26: 609625.
[162] Wells, S. (1993). "What do Birtmothers Want?". Adoption and Fostering 17 (4): 2226.
[163] "Why Birthmother Means Breeder," (http:/ / foundandlostsupport. com/ birthmothermeansbreeder. html) by Diane Turski
[164] Cultural Sensitivity and Political Correctness: The Linguistic Problem of Naming, Edna Andrews, American Speech, Vol. 71, No. 4
(Winter, 1996), pp.389-404.
[165] PAL 1992 (http:/ / www. adoptivefamilies. com/ pdf/ PositiveLanguage. pdf) OURS 1992
[166] Holt 1997 (http:/ / www. holtinternational. org/ adoption/ language. shtml) Holt International 1997
[167] Sayyid Muhammad Rivzi, "Adoption in Islam," (http:/ / www. jaffari. org/ files/ literature/ Adoption in Islam. pdf), April 09, 2010,
[168] Tim Lister and Mary Rogers, "Egypt says adoptive moms were human smugglers," CNN (http:/ / www. cnn. com/ 2009/ WORLD/ meast/
03/ 23/ egypt. adoption. trial/ index. html?eref=rss_world#cnnSTCText), March 23, 2009,
The language of adoption is changing and evolving, and since the 1970s has been a controversial issue tied closely
to adoption reform efforts. The controversy arises over the use of terms which, while designed to be more appealing
or less offensive to some persons affected by adoption, may simultaneously cause offense or insult to others. This
controversy illustrates the problems in adoption, as well as the fact that coining new words and phrases to describe
ancient social practices will not necessarily alter the feelings and experiences of those affected by them. Two of the
contrasting sets of terms are commonly referred to as positive adoption language (PAL) (sometimes referred to
respectful adoption language (RAL)), and honest adoption language (HAL).
Positive Adoption Language

In the 1970s, as adoption search and support organizations developed, there were challenges to the language in
common use at the time. The term "natural mother" had been in common use previously. The term "birth mother"
was first used in 1956 by Pearl S. Buck. As books like Adoption Triangle by Sorosky, Pannor and Baran were
published, and support groups formed like CUB (Concerned United Birthparents), a major shift from natural parent
to birthparent [1] [2] occurred. Along with the change in times and social attitudes came additional examination of the
language used in adoption.
Social workers and other professionals in the field of adoption began changing terms of use to reflect what was being
expressed by the parties involved. In 1979, Marietta Spencer, wrote "The Terminology of Adoption" for The Child
Welfare League of America (CWLA),[3] which was the basis for her later work "Constructive Adoption
Terminology".[4] This influenced Pat Johnston's "Positive Adoption Language" (PAL) and "Respectful Adoption
Language" (RAL).[5] The terms contained in "Positive Adoption Language" include the terms "birth mother" (to
replace the terms "natural mother" and "real mother"), "placing" (to replace the term "surrender").
Language at its best, honors the self-referencing choices of the persons involved, utilizes inclusive terms and
phrases, and is sensitive to the feelings of the primary parties. Language evolves with social attitudes and
19
20
experiences. The example below is one of the earliest and it should be noted that these lists, too, have evolved and
changed some over the years.[6] [7]
The reasons for its use: Some terms like birth parents, birth mother, birth father were chosen by those working in
adoption reform as terms to replace 'natural' and it took nearly a decade before agencies, social workers, courts and
laws embraced the change in self-referencing. Some adoptive parents supported this change as they felt using
"natural" indicated they were "unnatural". In some cultures, adoptive families face adoptism.[8] This can be evident
in English speaking cultures when there is prominent use of negative or inaccurate language describing adoption. So,
to combat adoptism, many adoptive families choose the use of positive adoption language.
The reasons against its use: Some birth parents see "positive adoption language" as terminology which glosses over
painful facts they face as they go into the indefinite post-adoption period of their lives. They feel PAL has become a
way to present adoption in the friendliest light possible, in order to obtain even more infants for adoption; i.e., a sales
and marketing tool. Some feel the social work system has negatively compromised the intention of the birth family
references and other terms, so that either the initial intent needs to be honored, or the terminology must again
change.
Example of terms used in Positive Adoption Language
Non-preferred:
PAL term:
Reasons stated for preference:
your own child
birth child; biological

child
Saying a birth child is your own child or one of your own children implies that an adopted child is
not.
child is adopted
child was adopted
Some adoptees believe that their adoption is not their identity, but is an event that happened to
them. ("Adopted" becomes a participle rather than an adjective.) Others contend that "is adopted"
makes adoption sound like an ongoing disability, rather than a past event.
give up for adoption
place for adoption or

make an adoption plan
"Give up" implies a lack of value. The preferred terms are more emotionally neutral.
real
mother/father/parent
birth, biological or
genetic
The use of the term "real" implies that the adoptive family is artificial, and is not as descriptive.
natural parent
birth parent or first

parent
The use of the term "natural" implies that the adoptive family is unnatural, and so is not a
descriptive or accurate term. Although it can be seen as unnatural to conceive and relinquish
children, the purpose is to present the adoption of those children in need as natural. The term
"natural" in its origin means a family by the natural means of conception and birth and its primal
bond which exists by itself since the beginning unless it's severed.
your adopted child
your child
The use of the adjective "adopted" signals that the relationship is qualitatively different from that
of parents to birth children.
surrender for
adoption
placed or placed for

adoption
The use of the adjective "surrendered" implies "giving up." For many parents placing a child for
adoption is an informed completely voluntary choice. For others, there is no choice as the parent's
rights were terminated because the parent was deemed to be unfit.
Honest adoption language

"Honest Adoption Language" refers to a set of terms that reflect the point of view that: (1) family relationships
(social, emotional, psychological or physical) that existed prior to the legal adoption continue, and that (2) mothers
who have "voluntarily surrendered" children to adoption (as opposed to involuntary terminations through
court-authorized child-welfare proceedings) seldom view it as a choice that was freely made, but instead describe
scenarios of powerlessness, lack of resources, and overall lack of choice.[9] [10] It also reflects the point of view that
the term "birth mother" is derogatory in implying that the woman has ceased being a mother after the physical act of
giving birth. Proponents of HAL liken this to the mother being treated as a "breeder" or "incubator".[11] Terms
21
included in HAL include the original terms that were used before PAL, including "natural mother", "Mother" and
"surrendered for adoption."
The reasons for its use: In most cultures, the adoption of a child does not change the identities of its mother and
father: they continue to be referred to as such. Those who adopted a child were thereafter termed its "guardians,"
"foster," or "adoptive" parents. Some people choose to use "Honest Adoption Language" (HAL) because it reflects
the original terminology. Some of those directly affected by adoption separation believe these terms more accurately
reflect important but hidden and/or ignored realities of adoption. They feel this language also reflects continuing
connection and does not exclude further contact.
The reasons against its use: The term "Honest" implies that all other language used in adoption is dishonest. HAL
does not honor the historical aspects of the early adoption reform movement who requested and worked years to
have terminology changed from natural to birth. Some adoptive parents feel disrespected by language like 'natural
parent' because it can indicate they are unnatural.
Example of Terms used in Honest Adoption Language
Non-preferred:
HAL Term:
Reasons stated for preference:
birth
mother or natural mother
HAL views term "birth mother" as being derogatory, limiting a woman's purpose in her
child's life to the physical act of reproduction and thus implying that she is a "former
mother" or "breeder." HAL terms reflect the point of view that there is a continuing
mother-child relationship and/or bond that endures despite separation
birth child
natural child, child of one's

own
HAL views the term "birth child" as being derogatory, implying that the adoptee was a
"birth product" produced for the adoption market, and having no relationship or
connection with his or her natural mother past the event of having been born. It also
implies that the mother is a "birth mother" with no connection to her child or interest in
her child past this point
place for adoption

give up for adoption
surrender for adoption

(have)
(are) separated by adoption,
HAL acknowledges that past adoption practice facilitated the taking of children for
adoption, often against their mother's expressed wishes. Many women who have gone
through the process and who are separated from their children by adoption believe that
social work techniques used to prepare single mothers to sign Termination Of Parental
Rights papers closely resembles a psychological war against natural motherhood; hence
[12]
the term "surrender."
"Surrender" is also the legal term for the mother's signing a
Termination of Parental Rights. "Realistic Plan", "Make a plan" and "place for adoption"
are viewed by HAL proponents as being dishonest terms which marginalize or deny the
[13]
wrenching emotional effect of separation on the mother/child dyad.
and imply the
mother has made a fully informed decision.
(when referring solely to
the parents who had
adopted)
adoptive
mother/father/parent/adopter
Referring to the people who have adopted the child as the mother or father (singular),
ignores the emotional and psychological (and often physical) presence of a second set of
parents in the child's life. In contrast to RAL, HAL reflects the opinion that there are two
sets of parents in the adopted person's life: adoptive parents and natural parents.
adopted child
adopted person or person

who was adopted
The use of the adjective 'adopted' signals that the relationship is qualitatively different
from that of parents to other children. The use of the word "child" is accurate up until the
end of childhood. After that the continued use of "child" is infantilizing.
Inclusive Adoption Language

There are supporters of various lists, developed over many decades, and there are persons who find them lacking,
created to support an agenda, or furthering division. All terminology can be used to demean or diminish, uplift or
embrace. In addressing the linguistic problem of naming, Edna Andrews says that using "inclusive" and "neutral"
language is based upon the concept that "language represents thought, and may even control thought."[14]
Advocates of inclusive language defend it as inoffensive-language usage whose goal is multi-fold:
1. The rights, opportunities, and freedoms of certain people are restricted because they are reduced to stereotypes.
2. Stereotyping is mostly implicit, unconscious, and facilitated by the availability of pejorative labels and terms.
3. Rendering the labels and terms socially unacceptable, people then must consciously think about how they
describe someone unlike themselves.
4. When labeling is a conscious activity, the described person's individual merits become apparent, rather than his or
her stereotype.
A common problem is that terms chosen by an identity group, as acceptable descriptors of themselves, can be then
used in negative ways by detractors. This compromises the integrity of the language and turns what was intended to
be positive into negative or vice-versa, thus often devaluing acceptability, meaning and use.
In this evolving debate about which terms are acceptable in any era, there can be disagreements within the group
itself. To be inclusive requires that no group ascribes to others what they must call themselves. Words and phrases
must reflect mutual respect and honor the individual choice.
Inclusive adoption language is far more than an aesthetic matter of identity imagery that one embraces or rejects; it
can focus the fundamental issues and ideals of social justice. Language that is truly inclusive affirms the humanity of
all the people involved, and shows respect for difference. Words have the power to communicate hospitality or
hostility, to exploit and exclude, as well as affirm and liberate. Inclusive language honors that each individual has a
right to determine for themselves what self-referencing term is comfortable and best reflects their personal identity.
References
[1] Birthparent Legacy Term (http:/ / www. sacredhealing. com/ triadoption/ Misc. / Origin of the Term Birthparent. pdf) TRIADOPTION
Archives
[2] Birth Parents (http:/ / darkwing. uoregon. edu/ ~adoption/ topics/ birthparents. htm) The Adoption History Project
[3] Adoption Terminology (http:/ / darkwing. uoregon. edu/ ~adoption/ archive/ CwlaAT. htm) Child Welfare League of American 1980s
[4] Adoption Language (http:/ / library. adoption. com/ articles/ a-few-words-on-words-in-adoption. html) by Brenda Romanchik
[5] Speaking Positively: Using Respectful Adoption Language (http:/ / www. perspectivespress. com/ pjpal. html), by Patricia Irwin Johnston
[6] PAL 1992 (http:/ / www. adoptivefamilies. com/ pdf/ PositiveLanguage. pdf) OURS 1992
[7] Holt 1997 (http:/ / www. holtinternational. org/ adoption/ language. shtml) Holt International 1997
[8] Adoptism defined (http:/ / www. pactadopt. org/ press/ articles/ adoptism. html)
[9] Logan, J. (1996). "Birth Mothers and Their Mental Health: Uncharted Territory", British Journal of Social Work, 26, 609-625.
[10] Wells, S. (1993). "What do Birthmothers Want?", Adoption and Fostering, 17(4), 22-26.
[11] "Why Birthmother Means Breeder," (http:/ / foundandlostsupport. com/ birthmothermeansbreeder. html) by Diane Turski
[12] Not By Choice (http:/ / www. eclectica. org/ v6n1/ buterbaugh. html), by Karen Wilson-Buterbaugh, Eclectica, 6(1), Jul/Aug 2001
[13] "The Trauma of Relinquishment, (http:/ / home. att. net/ ~judy. kelly/ thesis. htm)" by Judy Kelly (1999)
[14] Cultural Sensitivity and Political Correctness: The Linguistic Problem of Naming, Edna Andrews, American Speech, Vol. 71, No. 4 (Winter,
1996), pp.389-404.
22
Open adoption
Open adoption
Open adoption is an adoption in which the biological mother or parents and adoptive family know the identity of
each other. In open adoption, the parental rights of biological parents are terminated, as they are in "closed
adoptions" and the adoptive parents become the legal parents, yet the parties elect to remain in contact. Open
adoption has become the norm in most states in the adoption of newborns. But open can mean different things to
different people, as demonstrated below.
Pre-birth openness
The days are long past when a birth mother would go to an adoption agency to give up her child, then have that
agency take full responsibility in selecting the adoptive family, with the birth mother playing no role. While it is true
that decades ago, often only independent adoptions (usually adoptions initiated by an attorney) involved openness,
now most adoption agencies have some, or complete, openness as well. Although practices vary state by state, most
adoptions start with the birth mother reviewing dozens of photo-resume letters of prospective adoptive parents.
Usually, these are adoptive families who have retained that agency or attorney to assist them in the adoption process.
Most states permit full openness not just regarding identities, but also personal information about each other. Just as
the adoptive parents want to learn about the birth mothers life and health history, so does the birth mother want the
same information about the people she is considering as the parents for her child.[1]
When the birth mother has narrowed down her prospective adoptive parents to one, or a few, families, normally they
arrange to meet in person.[2] Good adoption agencies and attorneys do this in a pressure-free setting where no one is
encouraged to make an immediate decision.) If they are geographically distant from each other (as some adoptions
are interstate, with the birth mother living in a different state from the adoptive parents), the first meeting will
normally be by phone, then advance to a face-to-face meeting if the meeting by phone went as well as hoped. The
goal for both birth and adoptive parents at this stage is to make sure they are looking at the adoption in the same
way. Adoption is a lifetime commitment, and just like marriage, both the birth and adoptive parents want to make
sure the other is someone they can count on, both short and long term.[3]
Many birth mothers do more than just meet the adoptive parents once before the birth.[4] If they live close enough to
each other, it is not uncommon for the birth mother to invite the adoptive mother (or adoptive father too if the birth
mother wishes) to come to her doctor appointments. This lets the adoptive parent vicariously live through the birth
mother regarding the pregnancy, and lets the birth mother see the adoptive parent's joy and anticipation of soon
becoming a parent. The same is true at the hospital, where it is not unusual for the adoptive mother (and the adoptive
father, if that is the birth mothers wish) to be a labor coach, and be present for the delivery. Many birth mothers ask
the hospital staff to hand the baby to the adoptive parents first, so they can be the first people to hold their child,
before she has even done so.[5]
Post-birth openness
Although pre-birth openness is getting to be routine in newborn adoptions, there are more variations in the years
following the birth, after the adoption has been completed.[6] Some birth mothers want to get to know the adoptive
parents before the birth, but then wish to go their own way in life thereafter. Getting to know the adoptive family
gives her confidence in the placement and the knowledge she can feel secure in the childs future with the mom and
dad (or single parent) she selected. The birth mother may feel that future contact with the adoptive parents, or the
child, would be emotionally difficult for her.[7]
Likely the most common arrangement in open adoptions is for the adoptive parents to commit to sending the birth
mother photos of the child (and themselves as a family) each year, and short written updates, until the child reaches
the age of 18.[8] Often these photos and updates will be sent more than just once a year, such as the child's birthday
23
Open adoption
or other significant events. Sometimes an intermediary is selected to receive and forward the updates, and sometimes
it is done directly. This can be via mail, or more common recently, via email. Some adoptions are more open than
just sending photos and updates. Some birth and adoptive parents agree they would like to stay in face-to-face
contact. The amount of contact can vary greatly. It could be just a time or two in the first year. It could be once or
multiple times annually throughout the childs life.[9]
A few states permit the birth and adoptive parents to sign a contract of sorts, putting in writing any promises
regarding contact after the adoption is finalized. Even in those states which do not expressly have laws in this area,
these "open adoption agreements" can usually be prepared if the parties desire to formalize the agreement. Normally,
courts will find these agreements enforceable, as long as they serve the best interests of the child. It is not unusual for
these agreements to be more like "handshake" agreements, although they offer less protection to a birth parent if the
adoptive parent's promises were not honored.[10]
Which type of open adoption is best?

Adoption is like marriage. There are countless ways that a marriage can work. What is right for one couple will not
work for another. Adoptions are the same. What is important is that the birth mother and adoptive parents are honest
with each other regarding the type of adoption each truly hopes for, and one person does not just say what they think
the other wants to hear, then face a conflict later.[11]
Adoptive parents will want to talk about adoption to their child from a very early age.[12] (Even if the adoptive
parents were so inclined, hiding adoption is really not possible, as everyone the adoptive parents know - neighbors,
friends, relatives - all know the child joined their family via adoption, so to hide it from the child is nonsensical,
hiding something the child should see as prideful and joyful.) Every adoptive parent wants their child to be proud of
their adoption heritage and confident in themselves and their place in a family. With this thought in mind, more and
more adoptive parents are opening their minds to a more open adoption than they might initially imagined if desired
by the birth mother, thinking that the birth mothers role is somewhat like that of a distant relative. In other words,
the birth mother has no legal right to make parenting decisions, nor should she want to, but she still has love to offer.
The saying "It takes a village to raise a child" comes to mind. And adoptive parents should remember, if their child
ever has a medical emergency requiring a birth parents aid (bone marrow, kidney tissue, et cetera, which often only
a direct blood relative can provide), that birth parent will be the first person they search for.[13]
A good analysis for adoptive parents to emply in determining what is the right degree of openness is to put
themselves in the place of a birth mother and ask, "If I were pregnant, and giving up my child, what would make me
feel confident, and feel good about the placement?" Most birth mothers are loving, caring young women, wanting the
best for their baby, but which they can't provide. Many adoptive parents view her as someone they'd enjoy staying a
part of their lives, not to mention she was the person who created their family for them. Likewise, birth mothers
should be sensitive to the feelings of the adoptive parents, and put themselves in the role of an adoptive parent,
asking themselves how they would feel regarding a particular planned role in the new family.[14]
As a practical matter, some states seem to have more open adoptions than others. The more progressive states may
have a rough percentage accordingly:
Pre-birth contact, but no post-birth contact: 10% Pre-birth contact, and photos and updates only thereafter: 65%
Pre-birth contact, photos and updates, and one or two annual face-to-face get-togethers: 25%
In more conservative states, the percentages may look more like this:
Pre-birth contact, but no post-birth contact: 30% Pre-birth contact, and photos and updates only thereafter: 65%
Pre-birth contact, photos and updates, and one or two annual face-to-face get-togethers: 5% It is not unheard of for
birth mothers to request an open adoption, then disappear from the child and adoptive family's life.[15]
24
Open adoption
Open adoption and birth fathers

No disrespect is intended toward birth fathers in only discussing openness with birth mothers above. The reality,
however, is that few birth fathers elect to take a role in adoption, given the fact the pregnancies were usually
unplanned, and often there was no long-term relationship with the birth mother. For those few birth fathers who
volunteer to take a helpful and active role in creating the adoption situation for the adopting parents, the potential
benefits to a continuing relationship with the birth father can be just as viable as with a birth mother.
There are sometimes problems concerning birth mothers and adoption agencies who neglect to make sure the proper
paperwork is done on the birth father's part. It is crucial to remember that no child can be relinquished legally
without the birth father's consent. He must be given the chance to take full custody. For this purpose, many states
have important putative father registries, although some adoption activists see these as a hindrance rather than a help.
[16]
Open adoption and older children

What about the placement of older children? These can take two widely divergent paths. Generally speaking, when a
child has bonded to a birth parent (perhaps being raised by her or him for an extended time) then a need for an
adoptive placement arises, it is usually critical for that child's emotional welfare to maintain ties with the birth
parent. It's like uprooting a tree. If it is not transplanted in special manner, serious consequences can follow.
Sometimes a parent raised a child, but a problem has arisen, and parenting is no longer possible, and there are no
family members able to take over the parenting role, so adoption is the best option. [17]
Another way older children can be placed for adoption is where the birth parents' rights were terminated by a court
due to improper parenting: abuse, et cetera. Although the child may still foster idealized feelings for that failing
parent, it is not uncommon in these adoptions for there to be no contact between the child and adoptive parents, and
the birth parent.
History of openness in adoption

A closed adoption is an adoption in which the parties involved do not know the identities of each other. Closed and
secret records reassured adoptive parents from the fear of returning biological parents. The social stigma of
unmarried mothers, particularly during the BSE (Baby Scoop Era) 1945-1975 rendered "unwed mothers" social
outcasts. In a mother driven society after WWII infertile couples were also seen as deviant due to their inability to
bear children. The social experiment of taking the children from "unmarried mothers" and "giving them" to adoptive
parents became the norm during the BSE. These adoptions were predominantly closed. The records were sealed,
biological mothers were told to keep their child a secret, and adoptive parents told to treat the child "as if born
to".[18] [19]
By the 1980's, as the social stigma slowly decreased with Abortion Laws and ready access to birth control, domestic
adoption decreased dramatically. The adoption industry needed an incentive to entice mothers to surrender their
children for adoption, and "Open Adoption" was created. The fact that 80% of Open Adoptions close early after the
birth of a child, is not readily given to mothers of adoption separation before Consents are signed.
Although open adoptions are thought to be a relatively new phenomenon, in fact most adoptions in the United States
were open until the twentieth century. Until the 1930's, most adoptive parents and biological parents had contact at
least during the adoption process.[20] In many cases, adoption was seen as a social support: young children were
adopted out not only to help their parents (by reducing the number of children they had to support) but also to help
another family by providing an apprentice.
Adoptions became closed when social pressures mandated that families preserve the myth that they were formed
biologically. One researcher has referred to these families, that made every attempt to match the child physically to
their adoptive families, as 'as if' families.[21] [22]
25
Open adoption
Access to birth records

In nearly all US states, adoption records are sealed and withheld from public inspection after the adoption is
finalized. Most states have instituted procedures by which parties to an adoption may obtain non-identifying and
identifying information from an adoption record while still protecting the interests of all parties. Non-identifying
information includes the date and place of the adoptee's birth; age, race, ethnicity, religion, medical history, physical
description, education, occupation of the biological parents; reason for placing the child for adoption; and the
existence of biological siblings.
All states allow an adoptive parents access to nonidentifying information of an adoptee who is still a minor. Nearly
all states allow the adoptee, upon reaching adulthood, access to non-identifying information about their relatives.
Approximately 27 states allow biological parents access to non-identifying information. In addition, many states give
such access to adult siblings. Identifying information is any data that may lead to the positive identification of an
adoptee, biological parents, or other relatives. Nearly all states permit the release of identifying information when the
person whose information is sought has consented to the release. Many states ask biological parents to specify at the
time of consent or surrender whether they are willing to have their identity disclosed to the adoptee when he or she is
age 18 or 21.5. If consent is not on file, the information may not be released without a court order documenting good
cause to release the information. A person seeking a court order must be able to demonstrate by clear and convincing
evidence that there is a compelling reason for disclosure that outweighs maintaining the confidentiality of a party to
an adoption.[23] In Alabama, Alaska, Delaware, Kansas, New Hampshire, and Oregon, there is no requirement to
document good cause in order to access their birth certificates.[24] [25] [26] [27] Some groups, such as Bastard Nation,
One Voice,[28] and Origins USA,[29] campaign for adoptees' automatic access to birth certificates in other US states.
At age 18, people adopted in the United Kingdom, Australia, Europe and in several provinces in Canada are
automatically entitled to their birth certificates and may access their adoption records.[24]
References
[1] RAISING ADOPTED CHILDREN, by Lois Melina, Harper Paperbacks, 1993
[2] http:/ / www. adoption101. com
[3] http:/ / www. adoption101. com/ open_adoption. html
[4] DEAR BIRTH MOTHER, by Kathleen Silber and Phylis Speedlin, Corona Publishing 1991
[5] DEAR BIRTH MOTHER, by Silber and Speedlin
[6] adoption101.com
[7] THE OPEN ADOPTION EXPERIENCE, by Lois Melina and Sharon Kaplan Roszia, Harper Paperbacks, 1993
[8] ADOPTION: THE ESSENTIAL GUIDE TO ADOPTING QUICKLY AND SAFELY, by Randall Hicks, Perigee Press 2007
[9] ADOPTION: THE ESSENTIAL GUIDE TO ADOPTING QUICKLY AND SAFELY, by Hicks
[10] THE OPEN ADOPTION EXPERIENCE, by Melina and Roszia
[11] RAISING ADOPTED CHILDREN, by Melina
[12] http:/ / www. adoption101. com/ talk_about_adoption. html
[13] ADOPTION WITHOUT FEAR, by James Gritter, Corona Publishing, 1989
[14] MAKING ROOM IN OUR HEARTS, by Micky Duxbury, Routledge Press, 2006
[15] ADOPTION: THE ESSENTIAL GUIDE TO ADOPTING QUICKLY AND SAFELY, by Hicks
[16] THE OPEN ADOPTION EXPERIENCE, by Melina and Roszia
[17] MAKING ROOM IN OUR HEARTS, by Duxbury
[18] History of Adoption: Closed Adoption (http:/ / www. adoptionclubhouse. org/ 03_homework/ 02_history/ 07_closed. html), National
Adoption Center, , retrieved 2008-05-02
[19] Closed Adoption (http:/ / www. sharedjourney. com/ adoption/ closed. html), SharedJourney, , retrieved 2008-05-02
[20] Adamec & Pierce, 1991
[21] Yngvesson, Barbara (Spring 2003), "Going 'Home': Adoption, Loss of Bearings, and the Mythology of Roots", Social Text - 74 (Duke
University Press) 21 (1): 727
[22] Yngvesson, Barbara (Spring 2007), "Refiguring Kinship in the Space of Adoption", Anthropological Quarterly (George Washington
University Institute for Ethnographic Research) 80 (2): 561579, doi:10.1353/anq.2007.0036
[23] Access to Adoption Records (http:/ / www. childwelfare. gov/ systemwide/ laws_policies/ statutes/ infoaccessap. cfm), U.S. Department of
Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Childrens Bureau,
26
Open adoption
2006,
[24] http:/ / www. post-gazette. com/ pg/ 07316/ 833100-84. stm Retrieved 29th February 2008
[25] http:/ / www. unsealedinitiative. org/ html/ articles. html Accessed: 2nd March 2008
[26] http:/ / apostille. us/ news/ bill_looks_to_open_adoption_records. shtml Accessed: 2nd March 2008
[27] http:/ / adoption. about. com/ od/ adoptionrights/ a/ openingrecords. htm Accessed: 2nd March 2008
[28] One Voice, No Secrets Available: http:/ / www. onevoicenosecrets. org/ main/ Accessed: 27th April 2008.
[29] Origins USA position papers Available: http:/ / originsusa. memberlodge. org/ Default. aspx?pageId=24588 Accessed: 27th April 2008.
External links
adoption101.com (http://www.adoption101.com/open_adoption.html/)
Open Adoption and Family Services: How to Create a Child-Centered Open Adoption (http://www.openadopt.
org/open-adoptees/centered-open-adoption/)
Open Adoption, adoptive parent profiles , birth parent support (http://www.openadoption.com/)
Open Adoption Resources and Support (http://www.openadoptioninsight.org/)
Openadoption.org (http://www.openadoption.org/) A web site dedicated to practical advice and cautions in
work to achieve an open adoption
(http://www.canadaadopts.com/canada/open.shtml) Open adoption information and resources in Canada.
Open Adoption information for those interested in adoption (http://www.openadoption.net/)
www.AdoptionSmiles.com (http://www.adoptionsmiles.com): Adoption Smiles is a free listing service for
parents interested in open adoption.
Closed adoption
Closed adoption (also called "confidential" adoption and sometimes "secret" adoption) is the process by where an
infant is adopted by another family, and the record of the biological parent(s) is kept sealed. (Often, the biological
father is not recordedeven on the original birth certificate.) An adoption of an older child who already knows his
or her biological parent(s) cannot be made closed or secret. This formerly was the most traditional and popular type
of adoption, peaking in the decades of the post-World War II Baby Scoop Era. It still exists today, but it exists
alongside the practice of open adoption. The sealed records effectively prevent the adoptee and the biological parents
from finding, or even knowing anything about each other (especially in the days before the Internet). However, the
emergence of non-profit organizations and private companies to assist individuals with their sealed records has been
effective in helping people who want to connect with biological relatives to do so.
Background and procedure

Historically, the four primary reasons for married couples to obtain a child via closed adoption have been (in no
particular order) infertility, asexuality, having concern for a child's welfare (i.e. would not likely be adopted by
others), and to ensure the sex of the child (a family with five girls and no boys, for example). In 1917, Minnesota
was the first U.S. state to pass an adoption confidentiality and sealed records law.[1] Within the next few decades,
most United States states and Canadian provinces had a similar law. The reason for sealing records and doing a
closed adoption is to protect the adoptee and adoptive parents from disruption by the birth parents and in turn, to
allow birth parents to make a new life.
Many adopting parents in non-private adoptions would apply to a local, state licensed adoption agency. The agency
may be a member of the national Child Welfare League of America (CWLA).[2] (The CWLA and many adoption
agencies are still in operation today, but with an expanded and somewhat different agenda compared to past decades,
as the government has largely taken over some of their previous responsibilities.)
27
Closed adoption
Prior to adoption, the infant would often be placed in temporary and state-mandated foster care for a few weeks to
several months until the adoption was approved. This would also help ensure that he or she was healthy, that the
birthparent was sure about relinquishment, and that nothing was overlooked at the time of birth. Nowadays, this
practice is discouraged, as it prevents immediate bonding between the mother and child. Also, much better medical
testing is available, both prenatally and postnatally.
Once the adoption has been approved, the agency transfers the infant from foster care (if used) to the adoptive
parents. After the infant has spent a few weeks or months with the adoptive parents, a local judge formally and
legally approves the adoption. the biological mother can take back the child months after the placement of the child.
The biological mother has until the final court hearing. The infant is then issued a second, amended birth certificate
that states the adopting parents are the actual parents. This becomes the adopted person's permanent, legal birth
certificate. In the post WWII era laws were enacted which prevented both the adoptee and adoptive family to access
the original, and the information given to them can be quite limited (though this has varied somewhat over the years,
and from one agency to another). Originally, the sealed record laws were meant to keep information private from
everyone except the 'parties to the action' (adoptee, adoptive parent, birthparent and agency). Over time, the laws
were reinterpreted or rewritten to seal the information even from the involved parties.
In some states, (North Carolina, Georgia, Virginia) the city and county of the adoptees birth is changed on the
amended birth certificate, to where the adoptive parents were living at the time the adoption was finalized. Often, the
states will not give the adoptee the correct location of their birth. The hospital may also be omitted on the amended
birth certificate, especially if it primarily serves unwed mothers. In the USA, many such hospitals were run by the
Salvation Army, and named after its founder, William Booth. By the mid-1970s, all of these hospitals had closed due
to high costs and the reduced need for secrecy, as the social stigma of having a child out of wedlock in America had
decreased. More and more mothers were either raising their child as a single parent (often with the help of the newly
created institution of government welfare. Reg Niles, Directory of Hospitals, Orphanages, Adoption Agencies and
Maternity Homes was published in 1981 and contains information about most US and Canadian facilities. Adoption
Directory [3]
Searches and reunions

From the early 1950s when Jean Paton began Orphan Voyage, and into the 1970s with the creation of ALMA,
International Soundex Reunion Registry, Yesterday's Children, Concerned United Birthparents, Triadoption Library,
and dozens of other local search and reunion organizations, there has been a grass roots support system in place for
those seeking information and reunion with family.
Reunion registries were designed so adoptees and their birth parents, siblings or other family members can locate
one another at little or no cost. In these mutual consent registries, both parties must have registered in order for there
to be a match. Most require the adoptee to be at least 18 years old. Though they did not exist until late in the 20th
century, today there are many internet sites, chat rooms, and other online resources that offer search information,
registration and support.
From the very beginning, there have been Search Angels who help adoptees, siblings and birth families locate their
relatives for free. Usually, these are persons personally touched by adoption who do not feel anyone should be
charged a fee to get information about themselves or their family.
Laws are ever changing and in many states of the USA, most provinces in Canada, the UK and Australia there are
now various forms of open records giving adoptees and birth family members access to information in their files and
on each other.
Some states have confidential intermediary systems. This often requires a person to petition the court to view the
sealed adoption records, then the intermediary conducts a search similar to that of a private investigator. This can be
either a search for the birth mother at the request of the adoptee, or vice versa. Quite often, in the many years which
have passed since the adoptee was born, a birth mother or female adoptee has both moved to another address, and
28
Closed adoption
married or remarried resulting in a change of her surname. While this can make the search difficult and time
consuming, a marriage certificate may provide the needed clue as to the person's whereabouts. If and when the
intermediary is able to contact the birth mother (or adoptee), she is informed that her adopted child (or birth mother)
is inquiring about her. In many states, should this party indicate that he or she does not want to be contacted, by law,
the information would not be given out. Upon completion of the search in which the birth mother agrees to be
contacted, the intermediary usually sends the adoptee the official unamended birth certificate obtained from the
court. The adoptive parents' application to an adoption agency remains confidential, however.
The cost for a confidential intermediary and related court fees can be around $500, but varies by state and agency.
For persons who can not afford the fees, there is usually assistance available from the tax-payer supported state
department or the non-profit agency, and anyone can request from them how-to request this help. Most agencies
charge a fixed fee which includes everything, and only in the most extreme and unusual circumstances ask for
additional funds. If the adoptee is unable to locate (or would prefer to use a third person) to find his or her birth
father, often the same confidential intermediary can be used for an additional fee.
There are also private search companies and investigators who charge fees to do a search for or assist adoptees and
birth mothers and fathers locate each other, as well as to help other types of people searching. These services
typically cost much more, but like search organizations and search angels, have far greater flexibility in regards to
releasing information, and typically provide their own intermediary services. However, they may not circumvent the
law regarding the confidentiality process.
In all adoption searches, it is uncommon to find both the birth mother and father at the same time. A separate search,
if desired, can be done afterwards for the father. Since males seldom change their surnames, and the mother might
have additional information, it is usually easier than the initial search for the birth mother. In many cases, adoptees
are able to do this second search for their birth father by themselves (or they try before paying for assistance).
Females have statistically been somewhat more likely than males to search for their birth parents, and are far more
likely to search for their adopted children. Very often, the reason the infant was put up for adoption in the first place
was the birth father's unwillingness to marry or otherwise care for the child. Nevertheless, many birth fathers in this
situation have agreed to meet with their grown children decades later.
In recent years, DNA tests designed for genealogists have been used by adult adoptees to identify biological
relatives.[4]
Legal matters
Only a court order allows closed adoption records to be unsealed, which was quite uncommon prior to the early
1990s. A few cases have surfaced in which records were thought to have been sealed but were noteither by
mishandling or misunderstanding. Although rare, a small number of people have been prosecuted over the years for
violating the confidentially of sealed adoption records. In 1998, Oregon voters passed Measure 58 which allowed
adoptees to unseal their birth records without any court order. Some other states which formerly kept closed adoption
records sealed permanently by default have since changed to allowing release once the adoptee turns 18. However,
these laws were not made retroactive; only future adoptions subsequent to the laws' passage apply.
On June 1, 2009, Ontario, Canada opened its sealed records to adoptees and their birth parents, with a minimum age
of 18 for the adoptee, or one additional year if the birth parents initiate the request. Both parties can protect their
privacy by giving notice of how to be either contacted or not, and if the latter, with identifying information being
released or not. All adoptions subsequent to September 1, 2008 will be "open adoptions"[5]
For searches involving a confidential intermediary, the intermediary initiates obtaining the court order and is
reimbursed for doing so. However, once the court grants this, it is still confidential information to everyone else until
the other party agrees otherwise. (See the previous section.)
29
Closed adoption
Many states, though, still keep this information sealed even after the adoptee and the birth parents agree to know and
contact each other. A second court order would be required to have this information unsealed permanently. This is
well beyond the scope of the initial search, and what is covered by the payment to the intermediary. Should an
adoptee subsequently lose his or her unamended birth certificate, a court order may be required to obtain another one
(even if a photocopy is submitted).
The probate laws of most states in the U.S. prohibit an adoptee from automatically inheriting from his or her birth
parents. This applies regardless of whether or not the birth father participated in or agreed to the adoption. Had the
adoption not have taken place, any son or daughter would be an heir upon his or her father's deathregardless of
who his childhood caretakers were. There can be additional complications if the birth father has subsequently moved
to another state. Should a birth parent include an "unknown" adoptee in his or her will, the probate court has no
obligation to fulfill this type of request, while "known" adoptees may have the same status as non-family members.
However, there is some variation in probate laws from one state to another.
Criticism of closed adoption

Closed adoption has been increasingly criticized in recent years as being unfair to both the adoptee and his or her
birth parents. Some people believe that making the identities of a child's parents quite literally a state secret is a gross
violation of human rights. On the other hand, the birth mother may have desired the secrecy because of a premarital
affair.
In virtually all cases, the decision is up to the adoptive parents regarding how to inform the child that he or she has
been adopted, and at what age to do so, if at all. Although a non-profit adoption agency (if one is used) might mail
newsletters and solicit funds from the parents, traditionally, it has been extremely rare for them to communicate
directly with the child. (Usually, adoption agencies do not contain the word "adoption" in their name.)
Difficulties include the lack of a genetic medical history which could be important in disease prevention. Often, this
was not given at the time of adoption, and the father's history is usually little known even to the mother.
Adoptive parents may be less likely to consider the possibility that they are doing something wrong, and blame the
child's heredity. The parents may even unfavorably compare their adopted child with a near-perfect,
genetically-related "fantasy" child. This enables them to blame ordinary problems which all parents face on their
child's supposedly "defective" genes. Thus, while non-adoptive parents are focused on nurture, some adoptive
parents are solely focused on nature (i.e. heredity) instead. This results in what could have been an easily resolved
problem, going unresolved in families with adopted children, possibly accompanied by child abuse.[6]
For many years in New York State, adoptees had to obtain the permission of their adoptive parents (unless deceased)
to be included in a state-sponsored reunion registry regardless of the age of the adoptee. In some cases, older adults
or even senior citizens felt like they were being treated like children, and required to obtain their parents' signature
on the form. In a broader sense, they felt it could be inferred that adopted children are always children, and thus
second-class citizens subject to discrimination. The law has since been changed.[7]
Organizations and media

Most US states and Canadian provinces have independent non-profit organizations that help adoptees and their birth
parents initiate a search, and offers other adoption-related support. There are also independent and state funded
reunion registries that facilitate reuniting family members. The International Soundex Reunion Registry (ISRR) is
the oldest and largest. [8] The Salvation Army also provides information in helping those who were born or gave
birth in its maternity hospitals or homes (see the external links below). This is a change from previous decades, when
nothing was ever released without a rarely given or sought court order.
Many in the adoption community first learned of search and support resources through newspaper articles Adoption
Articles [9], the Dear Abby column Dear Abby [10] and various TV shows and movies. Starting in the mid-1980s,
30
Closed adoption
many adoptees and their parents first learned about the possibility of reunion on the NBC (later CBS) television
program Unsolved Mysteries hosted by Robert Stack. This was under their "Lost Loves" category, the vast majority
of which involved closed adoption. More than 100 reunions have occurred as a result of the program, many of those
being the adoption-related cases. Reruns of the program (with a few new segments and updates) were also aired on
the Lifetime Television cable network until mid-2006, and very briefly on Spike TV in late 2008. In September
2010, the program returned to Lifetime from 4 to 7 pm ET/PT.
External links
Salvation Army (former Booth Hospitals) [11]
ISRR Reunion Registry [12]
Adoption Archives [13]
References
[1]
[2]
[3]
[4]
Adoption History: Adoption History in Brief (http:/ / darkwing. uoregon. edu/ ~adoption/ topics/ adoptionhistbrief. htm)
Child Welfare League of America (http:/ / www. cwla. org)
http:/ / www. sacredhealing. com/ triadoption/ Reg%20Niles%20AAOMH. htm/
http:/ / www. DNA-Testing-Adviser. com
[5] http:/ / www. adoptontario. ca/ newsdetails. aspx?id=257

[6] The Adoption Triangle: Sealed or Opened Records: How They Affect Adoptees, Birth Parents, and Adoptive Parents ISBN 0-931722-59-4
[7] http:/ / www. nacac. org/ policyarticles/ accessbirthrecords. html
[8] http:/ / www. isrr. net
[9] http:/ / www. sacredhealing. com/ triadoption/ articles. htm/
[10] http:/ / www. isrr. net/ articles. htm
[11] http:/ / www1. usw. salvationarmy. org/ usw/ www_usw. nsf/ vw-text-dynamic-arrays/
88256D3D006526AD88256BD0007B4A98?openDocument
[12] http:/ / www. isrr. net/
[13] http:/ / www. triadoption. com/
31
Domestic adoption
Domestic adoption
Domestic adoption is the placing of a child within the same country as the childs birth. This may be achieved
through a private agency or the state, such as foster care.
Domestic adoption
Adoption is a legal process through which a child who will not be raised by his/her birth parents becomes a full and
permanent legal member of another family. In most jurisdictions, domestic adoption begins with the decision of the
birth parents to place their unborn baby or child with another family. Birth parents may play an active role in the
adoption process and may be involved in selecting an adoptive family. There are several ways in which birth and
adoptive families connect, such as through a personal contact or an adoption professional (e.g., private or state-run
adoption agency, a private attorney, or in some states a facilitator). Privately-arranged adoptions through an attorney
or facilitator are illegal in some jurisdictions. In a private adoption, birth parents may have the option of choosing an
open, semi-open, or confidential (a/k/a closed) adoption. Birth parents may be given profiles of waiting adoptive
families to look at and choose from. In doing so, they become active participants in the adoption process and may
experience greater confidence in their adoption plan. In the alternative, birth parents may request assistance from
their adoption professional in choosing an adoptive family. http://www.allforchildren.org/adoptionchoices.html
Open adoption
See also: Open adoption
Open adoption is where the adopted person has access to their file and/or original records. This may be a right
available at certain ages - e.g., at age 18, a person adopted in the United Kingdom becomes entitled to their birth
certificate and may access their adoption records.
Open adoption may also be defined as a type of private adoption. Open adoption involves a degree of ongoing
personal contact between the parties to an adoption (the birth parents, adoptive family and the child). Identifying
information is shared between the parties (such as names, addresses, and phone numbers). The parties will determine
the nature and extent of contact and this is often communicated and managed directly -- without the assistance of an
intermediary. Even after an adoption is finalized, the relationship between the parties will continue, and may include
yearly pictures, visits, phone calls, letters, or e-mails. While all adoption plans are unique, in an open adoption the
adopted child may meet his/her birth family and/or a degree of ongoing communication will exist. http:/ / www.
allforchildren.org/adoptionchoices.html
===Semi-open adoption Semi open adoption in private adoption involves a degree of contact between the birth and
adoptive parents, but this contact is limited and only non-identifying information is shared. For example, first names
and the state/region in which the parties reside may be disclosed. Communication is often made through an
intermediary, such as an adoption agency. Significantly, birth parents may play an active role in selecting an
adoptive family and receive pictures and letter updates through the agency. Thanks to technology advances, the
parties may choose to stay connected through the internet in a non-identifying manner (e.g., creating a dedicated
website with picture and video uploads of child milestones for birth parent viewing).http://www.allforchildren.org/
adoptionchoices.html
32
Domestic adoption
Confidential (a/k/a closed) adoption

See also: Closed adoption
In some confidential adoptions, non-identifying information is shared between the parties involved, such as medical
history and social background, up to the point of placement. After the adoption is legalized, no further information is
shared between the adoptive parents and the birth parents.<refhttp://www.allforchildren.org/domestic.html</ref>
In other confidential adoptions no information is shared between the parties involved. This may occur because of the
law in the jurisdiction concerned, or court order, such as when a child is removed form the home by the state because
of abuse or neglect. It may also occur because the parties involved do not want any contact.
Foster Care adoptions

Foster care is a form of substitute care, usually in a home licensed by a public agency, for children whose welfare
and protection requires that they be removed from their own homes (often due to claims of abuse or neglect). Foster
care adoption is a legal process through which children in the public, foster care system become full and permanent
legal members of another family.
External Links
www.allforchildren.org [1]
familyformation.com [2]
References
[1] http:/ / www. allforchildren. org
[2] http:/ / www. Familyformation. com/
http://www.allforchildren.org/adoptionchoices.html
33

Foster care adoption is a type of domestic adoption where the child is initially placed into a foster care system and
is subsequently placed for adoption. Children may be placed into foster care for a variety of reasons, including
removal from the home by a governmental agency because of maltreatment.[1] In some jurisdictions, adoptive
parents are licensed as and technically considered foster parents while the adoption is being finalized.[2]
Trends and Research

Nationwide, there are more than one hundred thousand of children in the U.S. foster care system waiting for
permanent families.[3] Child welfare professionals must recruit potential adoptive families for these children who are
waiting for adoption.
A national survey by Harris Interactive revealed that 48 million Americans considered adoption from foster care in
2007, however:[4]
- 67% were unnecessarily concerned that biological parents could return to claim the children; once the court
finalizes the legal termination of parental rights, the parents can never return to claim the child.
- 46% mistakenly believed that foster care adoption is prohibitively expensive, when in reality there is very little cost
to adopt from foster care, and there is financial support available for all adoptions.
- 36% were unsure or confused about the adoption process.
- 45% believed children in foster care have entered the system because of juvenile delinquency. In reality, the vast
majority of the 129,000 children waiting in the U.S. foster care system entered through no fault of their own, as
victims of neglect, abandonment and/or abuse.
Supporting Organizations
The Dave Thomas Foundation for Adoption, founded by Wendys founder Dave Thomas, is a not-for-profit
organization that supports foster care adoption and provides grants to national and regional adoption organizations
for programs to raise awareness and make adoption easier and more affordable.
References
[1]
[2]
[3]
[4]
http:/ / www. hhs. gov/

http:/ / www. childwelfare. gov/ adoption/ foster/
http:/ / www. davethomasfoundation. org/
http:/ / www. davethomasfoundation. org/ Our-Work/ Research
External links
A Child is Waiting: A Step-by-Step Guide to Adoption (http://www.davethomasfoundation.org/
Free-Adoption-Resources/Adoption-Guides)
http://en.wikipedia.org/wiki/Domestic_adoption
34
International adoption (also referred to as intercountry adoption or transnational adoption) is a type of adoption
in which an individual or couple becomes the legal and permanent parents of a child that is a national of a different
country. In general, prospective adoptive parents must meet the legal adoption requirements of their country of
residence and those of the country whose nationality the child holds.
International Adoption is not the same thing as Transcultural or Interracial adoption.
The laws of different countries vary in their willingness to allow international adoptions. Some countries, such as
China and Korea, have relatively well-established rules and procedures for international adoptions, while other
countries expressly forbid it. Some countries, notably many African nations, have extended residency requirements
for adoptive parents that in effect rule out most international adoptions. Malawi, for instance, requires residency
except in special cases.[1]
Process overview
The requirements necessary to begin the process of international adoption can vary depending on the country of the
adoptive parent(s). For example, while most countries require prospective adoptive parents to first get approval to
adopt, in some the approval can only be received from a state agency, while in others cases, it can be obtained from a
private adoption agency.
In the United States, typically the first stage of the process is selecting a licensed adoption agency or agency to work
with. Each agency or attorney works with a different set of countries, although some only focus on a single country.
Pursuant to the rules of the Hague Convention (an international treaty related to adoption issues) the adoption agency
or attorney must be accredited by the U.S. government if the child's country is also a participant in the Hague
Convention. If the child's country is not a participant in the Hague Convention, then the rules of the Hague do not
apply, and instead the specific laws of the child and adoptive parents must be followed. Even when the Hague does
not apply, a home study and USCIS (United States Citizen and Immigration Services)(formerly INS (Immigration
and Naturalization Service) approval are requirements.[2] The Hague is discussed below.
A dossier is prepared that contains a large amount of information about the prospective adoptive parents required by
the child's country. Typically this includes financial information, a background check, fingerprints, a home study
review by a social worker, report from the adoptive parents' doctor regarding their health, and other supporting
information. Again, requirements will vary widely from country to country, and even region to region in large
countries such as Russia. Once complete, the dossier is submitted for review to the appropriate authorities in the
child's country.[3]
After the dossier is reviewed and the prospective parents are approved to adopt, they are matched to an eligible child
(except in some countries such as India, which does not allow "matching" of a child to (a) prospective parent(s)).
The parent is usually sent information about the child, such as age, gender, health history, etc. This is generally
called a referral. A travel date is typically included, informing the parents when they may travel to meet the child and
sign any additional paperwork required to accept the referral. Some countries, such as Kazakhstan, do not allow
referrals until the prospective parent travels to the country on their first trip. This is called a "blind" referral.
Depending on the country, the parents may have to make more than one trip overseas to complete the legal process.
Some countries allow a child to be escorted to the adoptive parents' home country and the adoptive parents are not
required to travel to the country of their adopted child.
There are usually several requirements after this point, such as paperwork to make the child a legal citizen of the
adopting parents' country or re-adopt them. In addition, one or more follow up (or "post placement") visits from a
social worker may be required either by the placing agency used by the adoptive parents or by the laws of the
country from which the child was adopted. In the United States, citizenship is automatically granted to all
35
foreign-born children when at least one adoptive parent is a U.S. citizen, in accordance with the Child Citizenship
Act of 2000. Depending on the circumstances of the adoption, the actual grant of citizenship takes place either upon
the child's admission to the U.S. as an immigrant or the child's adoption in the parent's home jurisdiction.[4]
Policies and requirements

Adoption policies for each country vary widely. Items such as the age of the adoptive parents, financial status,
educational level, marital status and history, number of dependent children in the house, sexual orientation, weight,
psychological health, and ancestry are used by different countries to determine what parents are eligible to adopt
from that country.
Items such as the age of the child, fees and expenses, and the amount of travel time required in the child's birth
country, can also vary widely from one country to another.
Each country sets its own rules, timelines and requirements surrounding adoption, and there are also rules that vary
within the United States for each state. Each country, and often each part of the country, also sets its own rules about
what type of information will be shared and how it will be shared (e.g. a picture of the child, child's health).
Reliability and verifiability of the information is also variable.
Most countries require that a parent travel to bring the child home; however, some countries allow the child to be
escorted to his or her new homeland.
The U.S. Department of State has designated two accrediting entities for organizations providing inter-country
adoption services in the United States that work with sending countries that have ratified the Hague Convention on
Protection of Children and Co-operation in Respect of Intercountry Adoption. They are the Council on Accreditation
and the Colorado Department of Health and Human Services. [5] The U.S. Department of State maintains a list of all
accredited international adoption providers. [6]
Sources of children and adoptive parents

The most common countries for international adoption by parents in the United States for 2007 were China (5453),
Guatemala (4728), Russia (2310), Ethiopia (1255), South Korea (939), Vietnam (828) Ukraine (606), Kazakhstan
(540), India (416) Liberia (353), Colombia (310), and Philippines (265).(U.S. State Department) [7] Other less
common countries include Bulgaria, Norway, Australia, Kenya, Canada, Haiti, and Poland. These statistics can vary
from year to year as each country alters its rules; Romania, Belarus and Cambodia were also important until
government crackdowns on adoptions to weed out abuse in the system cut off the flow. Vietnam recently signed a
treaty openings its doors for adoption. Guatemala has recently closed its doors.
Although Nepal has not closed it doors for adoption, the United States government has suspended adoptions from
Nepal. Documents that were presented in support of the abandonment of these children in Nepal have been found to
be unreliable and circumstances of alleged abandonment cannot be verified because of obstacle in the investigation
of individual cases.[8]
China is the one major country where girls adopted far outnumber boys; due to the Chinese culture's son preference
in combination with the official planned birth policy implemented in 1979, about 95% of Chinese children adopted
are girls. Although India also has a noticeable excess of girls being adopted (68% girls), most other countries are
about even. South Korea is the one country that has a relatively large excess of boys being adopted; about 60% are
boys. This is a switch from the 1980s, when most Korean adoptees (about two-thirds) were girls.
Adoption from Ethiopia has become an increasingly popular option for adoptive families in the US. According to the
U.S. Department of State,[9] there were 441 orphans visas issued to Ethiopian children in 2005, and 732 issued in
2006.[10]
36
International Adoption Laws

A country's willingness to allow international adoption will vary to accommodate that country's laws. Some
countries, such as China and Vietnam, have relatively well-established rules and procedures for foreign adopters to
follow, while others, the United Arab Emirates (UAE) for example, expressly forbid it. Some countries, notably
many African nations, have extended residency requirements that in effect rule out most international adoptions.
Others, such as Romania are closed to international adoption altogether, with the exception of adoptions by close
relatives (such as grandparents). However, as of 2009, many countries around the world are completely closed off to
international adoption because of accusations of exporting children, of selling natives to foreigners and the shame
that most governments feel about not being able to support their own children.
Hague Conference on Private International Law

See also Hague Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption
Recognizing some of the difficulties and challenges associated with international adoption, and in an effort to protect
those involved from the corruption and exploitation which sometimes accompanies it, the Hague Conference j on
Private International Law developed the Convention on Protection of Children and Co-operation in Respect of
Intercountry Adoption,[11] which came into force on 1 May 1995.
The main objectives of the Convention are:
to establish safeguards to ensure that intercountry adoptions take place in the best interests of the child and
with respect for his or her fundamental rights as recognized in international law;
to establish a system of co-operation amongst Contracting States to ensure that those safeguards are respected
and thereby prevent the abduction, the sale of, or traffic in children;
to establish "formal international and intergovernmental recognition of intercountry adoption, working to
ensure that adoptions under the Convention will generally be recognized and given effect in other party
countries";[12]
to secure the recognition in Contracting States of adoptions made in accordance with the Convention.
As of October 2008, this Convention has been ratified by 76 countries. Ireland and the Russian Federation are
signatories, but have not ratified.[13]
The following is a quotation from the convention:
Intercountry adoptions shall be made in the best interests of the child and with respect for his or her
fundamental rights. To to prevent the abduction, the sale of, or traffic in children each State should take,
as a matter of priority, appropriate measures to enable the child to remain in the care of his or her family
of origin.[14]
However, while the Hague Convention is an excellent ideal, in implementation it could actuality impede many
adoptions. A country like Guatemala, which has had a plethora of child trafficking, prostitution and many orphans,
are now temporarily closed to adoptions after the country's ratification of the Hague Convention. The convention
causes some governments like India to run incredibly slow, creates a rigorous process that few pass, and instead of
helping the children get out of orphanages, it keeps them inside them, getting older and older until they pass the age
of adoption and simply wait until they are legal adults. Most children who grow up in orphanages and become legal
adults get very little in the way of education, most become unemployed, or pregnant and begin the vicious cycle all
over again.
While the Hague convention is an exemplary step in the right direction by most governments, it could sometimes
actually hinder many adoptions to families that would normally qualify and causing children to miss opportunities
that could have saved and changed their lives.[15]
37
UN Declaration Relating to the Welfare of Children

The UN declaration Relating to the Welfare of Children emphasises the preference for children being raised by
family members, rather than by adoptive families. The child shall, wherever possible, grow up in the care and under
the responsibility of his parents and, in any case, in an atmosphere of affection and of moral and material security.
The Declaration makes clear that international adoption should only be considered as a last resort. This is explained
in Article 15 If a child cannot be placed in a foster or an adoptive family or cannot in any suitable manner be cared
for in the country of origin, intercountry adoption may be considered as an alternative means of providing the child
with a family. In such a situation, the Declaration also advocates time and patience in the adoptive process, i.e. not
rushing into adoptions in the wake of disasters. Article 15 states Sufficient time and adequate counselling should be
given to the child's own parents, the prospective adoptive parents and, as appropriate, the child in order to reach a
decision on the child's future... Clearly, the UN Declaration is against the idea of international adoption as a whole,
and is most certainly against rushed international adoption.[16]
Consequences and problems

Negative consequences of international adoption
See: List of international adoption scandals
Child trafficking or child laundering
Child trafficking is a broad term that refers to the buying, selling or illegal transportation of children. Child
laundering is a more precise term that refers to the stealing of children who are then sold to adoptive parents as
legitimate "orphans." Often the pretence is that the child's parents are dead when in fact the child's parents are still
alive. In some cases the children are stolen from the home; in other cases the children are left at orphanages for
temporary care or schools for education. These then sell the children using false papers. In some cases the parents
may even sell the children.[17] This trafficking can occur anywhere but is most prominent in poorly regulated
countries or where local corruption is a factor. Up to the end of 2007, Guatemala, was one of the top sources of
adopted children, and was investigated for this sort of corruption.[18] Guatemala changed the country's adoption law
after massive international pressure, ratified the Hague-convention on intercountry adoptions, and the number of
adoptions has fallen dramatically.
While most international adoptions are not tainted by child trafficking, some problems do exist. Receiving nations
such as the United States have implemented safeguards to ensure that adopted children are in fact legally available
for adoption. Occasionally, the United States has suspended adoption from certain countries in order to investigate
fraud and, where needed, require change from the sending country.[19]
Richard Cross, the lead federal investigator for the prosecution of Lauryn Galindo for visa fraud and
money laundering involved in Cambodian adoptions, estimated that most of the 800 adoptions Galindo
facilitated were fraudulent--either based on fraudulent paperwork, coerced/induced/recruited
relinquishments, babies bought, identities of the children switched, etc.[20] [21]
The Hague Convention on Intercountry Adoption (short title for Convention #33) is one measure intended to further
shield international adoption against child trafficking.
Loss of culture, family or identity
International adoption is a relatively new phenomenon when compared to domestic adoption. One of the debates in
international adoption circles has been about the adopted childs sense of belonging in their new country. Some
believe that this is a particular concern for inter-racial adoptions. For example, Asian children who are adopted by
Caucasians are of a recognizably different race than their adoptive parents, and might be expected to have a harder
time fitting in than, say, a Russian child.
38
Nowadays, however, the children and adoptive parents are encouraged to explore their origins of birth. From their
birth parents, to their birth cultures exploration is almost expected. For example, Korea holds cultural training
camps where Korean adoptees are able to explore their birth country for the first time. Until recently, Korean
adoptees were seen as outcasts, and these training camps are the Korean governments way of changing the view of
these outcasts to overseas Koreans. It has slowly shown positive results, and a closer kinship of adoptees to their
birth country.
Questions still remain. Is it detrimental to a childs well-being to keep them from getting to know their birth origin?
Or are more problems caused by encouraging and allowing foreign adoptees to explore their birth culture? Also, how
should the adoptive parents prepare to deal with a bi-racial family in which the adults are of one race while the child
is of another? And how do we reconcile differences between adoptive parents' assumptions about adoption with
adoptees' experiences of living with a condition that they were too young to decide on for themselves? As of right
now, a critical mass of scholars, adoption professionals and community representatives are only beginning to explore
these questions with the growing community groups made up of international adoptees (many who have finally now
reached maturity). Anthropologists, for example, have very recently started to study the effects of kinship,
belonging, culture, nation, and even genes and the roles they play in the upbringing of foreign adoptees. As Pauline
Turner Strong said in an article in Relative Values: Reconfiguring Kinship Studies: "Adoption across political and
cultural borders may simultaneously be an act of violence and an act of love, an excruciating rupture and a generous
incorporation, an appropriation of valued resources and a constitution of personal ties.
Scholarly accounts in journal articles, higher-degree studies and books by authors such as Toby Volkman, David
Eng, Sara Dorow, Indigo Willing and Tobias Hubinette also suggest that adoption is a contested practice, with a
variety of competing voices ranging from adoptive parents who not only adopt but also dominate published accounts
of the practice, to those who have been internationally adopted and are now beginning to enter research fields
focusing on adoption (such as members of the International Adoptee Congress Research Committee).
All these researchers now have the benefit of drawing on populations of the "first waves" of internationally adopted
people who have now reached adulthood, as seen in the rise of Korean and Vietnamese adoptee groups alone. At the
same time, it is hard to determine any sort of best practice in adoption if only based on conflicting research agendas,
paradigms and narratives presented by psychologists, sociologists, and anthropologists alike. More serious
consultation with a range of internationally adopted people from various professional and community-work based
backgrounds needs to be included before the field of adoption study is more truly representative and rigorously
informed.
The origin of the child also plays a role in whether he will adjust to adoption well. Children from orphanages, for
example, have rarely ever slept in a room by themselves at night. When they are adopted and given a room of their
own, they show likelihood to develop sleeping problems and ill health can result from their adjustment. It helps if
parents allow the child to sleep in their bedroom, or in the bedroom of a sibling. Cultural backgrounds can affect
adjustment as well. For example, children from Russia are in high demand the adoption market in the United States.
Because of this, the price to adopt a child from Russia is very high,[22] and Russian adoption agencies have become
more of a business than a method to provide for children in need. Prior to adoption, children are neglected in
orphanages, often do not receive proper nutrition, and are used as a bartering tool to make money. When these
children are adopted, they are likely to act out because of the negative treatment they received in their country of
origin. Cultural treatment of children and political situations in countries affect children when they are adopted
internationally.[23] Even being of a different race than the adopted family can cause the adoptee to feel like a misfit.
39
Positive consequences of international adoption

In most cases, international adoption results from a child whose birthparents were unable to parent and provide for
them within the environment of a family instead of an institution such as an orphanage. This can mean the difference
between a life and death. In other cases, the children may be saved from a life of desperation, abuse, and squalor.
Every child needs a family. [The Irreducible Needs of Children: What Every Child Must Have to Grow, Learn, and
Flourish; Copyright 2000 by T. Berry Brazelton, M.D. and Stanley I. Greenspan, MD; ISBN 0-7382-0516-8]
Further, adopted children are happier and healthier, mentally and physically, than are orphans who are not adopted.
[Brodzinsky, D. M. "Long-Term Outcomes in Adoption." The Future of Children 3, 1993]
A recent study by Dutch professor Femmi Juffer challenges the notion that adoption hurts a childs self-esteem in
that adopted kids would unconsciously blame themselves for the loss of their birth families and on some level feel
that they hadn't been good enough for their families to keep them. Juffer compiled data from 80 studies and
concluded that adopted children are not at risk for low self esteem, even in the case of interracial adoptions and
international adoptions. Differences in race between a child and their adoptive parents did not matter and children
from interracial/international-adoption families performed the same as children adopted into families of the same
race/culture. In the long term cultural differences were not as problematic as expected, and even older adopted
children, those thought to be the most difficult and more severely and permanently damaged, adjusted over time as
well. Overall, although adoption may have initial adverse effects and negative experiences for childhood, the
children are capable of change and development for the better. But Steven Nickman of Harvard Medical School, who
recently did a review of the adoption literature, says that while Juffer's study is careful and methodologically sound,
there are some limits to her research. Essentially, Nickman says, the study doesn't include any of the most difficult
cases and as someone who works with adopted kids, Nickman knows that not all adoptions turn out well. Some are
incredibly painful. Still, he finds Juffer's work encouraging.[24]
Reform efforts
Due to the appeal and otherwise obvious difficult issues presented by international adoption, the reform movement
seeks to influence governments to adopt regulations that serve the best interest of the child and meet the interests of
both the adoptive and biological family members.[25] Significant advances have been made in increasing the
regulation of International Adoptions. Hague Convention on Protection of Children and Co-operation in Respect of
Intercountry Adoption
International Adoption After a Disaster

Of special note to international adoption are campaigns for adoptions that occur after disasters such as hurricanes,
tsunamis, and wars. There is often an outpouring of adoption proposals in such cases from foreigners who want to
give homes to children left in need. While adoption may be a way to provide stable, loving families for children in
need, it is also suggested that adoption in the immediate aftermath of trauma or upheaval may not be the best
option.[26] Moving children too quickly into new adoptive homes among strangers may be a mistake because with
time, it may turn out that the parents have survived but were unable to find the children, or there may be a relative or
neighbor who can offer shelter and homes. Providing safety and emotional support may be better in those situations
than immediate relocation to a new adoptive family.[27] There is also an increased risk, immediately following a
disaster, that displaced and/or orphaned children may be more vulnerable to exploitation and child trafficking.[28]
40
References
[1] The lessons of Idah's long journey from Malawi to Burlington (http:/ / www. theglobeandmail. com/ news/ world/
idahs-long-journey-from-malawi-to-burlington/ article1191477/ )
[2] http:/ / www. adoption101. com/ international_adoption. html
[3] ADOPTION: THE ESSENTIAL GUIDE TO ADOPTING QUICKLY AND SAFELY, by Randall Hicks, Perigee Press 2007
[4] "Adoption: Before Your Child Immigrates to the United States" (http:/ / www. uscis. gov/ portal/ site/ uscis/ menuitem.
eb1d4c2a3e5b9ac89243c6a7543f6d1a/ ?vgnextoid=d72e18a1f8b73210VgnVCM100000082ca60aRCRD&
vgnextchannel=d72e18a1f8b73210VgnVCM100000082ca60aRCRD). United States Citizenship and Immigration Services. September 2,
2009. . Retrieved February 28, 2011.
[5] http:/ / www. adoption. state. gov/ hague/ accreditation/ process. html
[6] http:/ / www. adoption. state. gov/ hague/ agency4. php?q=0& q1=& q2=0& q4=0& q5=0& dirfld=01
[7] http:/ / travel. state. gov/ family/ adoption/ stats/ stats_451. html
[8] http:/ / eaci. com/
[9] U.S. Department of State (http:/ / www. state. gov/ )
[10] U.S. Department of State, orphans visas from Ethiopia (http:/ / travel. state. gov/ family/ adoption/ stats/ stats_451. html)
[11] Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption (http:/ / hcch. e-vision. nl/ index_en.
php?act=conventions. text& cid=69)
[12] Understanding the Hague Convention-Adoption.gov (http:/ / adoption. state. gov/ hague_convention/ overview. php)
[13] Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption (http:/ / www. hcch. net/ index_en.
php?act=conventions. status& cid=69)
[14] Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption (http:/ / www. hcch. net/ index_en.
php?act=conventions. pdf& cid=69)
[15] http:/ / www. hopeadoption. org/
[16] http:/ / www. un. org/ documents/ ga/ res/ 41/ a41r085. htm
[17] David Smolin, Works at bepress legal repository, at (http:/ / works. bepress. com/ david_smolin/ )
[18] Washington Post, Guatemala adoption investigation, at (http:/ / www. washingtonpost. com/ wp-dyn/ content/ article/ 2007/ 01/ 11/
AR2007011102542. html)
[19] Smolin, works (http:/ / works. bepress. com/ david_smolin/ )
[20] Desiree Smolin and David Kruchkow, Why Bad Stories Must Be Told, The Adoption Agency Checklist, (http:/ / www.
adoptionagencychecklist. com/ page794. html)
[21] Full lecture of special agent Richard Cross Richard Cross's full video and audio lecture available here (http:/ / cumberland. samford. edu/
cumberland_programs. asp?ID=630)
[22] Marre, Diana and Laura Briggs. International adoption: global inequalities and the circulation of children.
[23] Marre, Diana and Laura Briggs. International adoption: global inequalities and the circulation of children.
[24] NPR "Study: Adoption Not Harmful to Child's Self-Esteem" (http:/ / www. npr. org/ templates/ story/ story. php?storyId=16572430)
[25] Adopting Internationally.com (http:/ / www. adoptinginternationally. com/ )
[26] http:/ / www. adoptioninstitute. org/ publications/ policybriefs. html Evan B. Donaldson Adoption Institute
[27] http:/ / www. adoptionboard. ie/ booklets/ Adoption_Board_Tsunami_statement. doc The Adoption Board
[28] http:/ / www. adoptionboard. ie/ booklets/ Hague_Tsunami_statement. doc The Adoption Board
Further reading
Rosenberg, Elinor B., The Adoption Life Cycle : the children and their families through the years (http://books.
google.com/books?id=Cu90JIcPIqQC&printsec=frontcover), New York : Free Press ; Toronto : Maxwell
Macmillan Canada ; New York : Maxwell Macmillan International, 1992. ISBN 0-02-927055-3.
External links
adoption101.com (http://www.adoption101.com/)
Hague Conference - Convention of 29 May 1993 on Protection of Children and Co-operation in respect of
Intercountry Adoption (http://www.hcch.net/index_en.php?act=conventions.text&cid=69)
David M. Smolin - Child Laundering: How the Intercountry Adoption System Legitimizes and Incentivizes the
Practices of Buying, Trafficking, Kidnapping, and Stealing Children (http://law.bepress.com/expresso/eps/
749/).
41
Interracial adoption (also referred to as transracial adoption) refers to the act of placing a child of one racial or
ethnic group with adoptive parents of another racial or ethnic group.
Interracial adoption is not the same thing as transcultural or international adoption though in some circumstances an
adoption may be interracial, international, and transcultural.
Statistics
Based on the Adoption and Foster Care Analysis and Reporting System (AFCARS), the fiscal year of 1998 showed
that approximately 64% of children waiting in foster care are of minority background; 32% are white. Out of all
foster children waiting for adoption 51% are black, 11% are Hispanic, 1% are American Indian, 1% are
Asian/Pacific Islander, and 5% are unknown/unable to determine. Data from the 1995 National Survey of Family
Growth (NSFG) show that adoption of an unrelated child was most common among childless white women and
those with higher levels of income and education. The most recent estimate of interracial adoption was performed in
1987 by the National Health Interview Survey (NHIS) and it found that 1% of white women adopt black children,
5% of white women adopt children of other races, and 2% of women of other races adopt white children (estimates
include foreign-born).[1]
The US Census 2000 found that "White (and no other race), not Hispanic children made up the majority of all
categories of children of householders under 18: about 58 percent of adopted children, 64 percent of biological
children" and "Of the 1.7 million households with adopted children, about 308,000 (18 percent) contained members
of different races."[2]
History
Before World War II it was very rare for white couples to adopt a child of a different race and every effort was made
in order to match a child with the skin color and religion of the adoptive family. Then in 1944 the Boys and Girls
Aid Society took an interest in the increasing number of minority children waiting to be adopted which focused on
children from Asian American, Native American, and African American heritage. Children of Asian and Native
American heritage were most easily placed outside of their racial group while those African Americans heritage
proved more difficult. The campaign was called "Operation Brown Baby" and its objective was to find adoptive
homes even if from a different race. Then during the civil rights movement, interracial adoptions in the United States
increased dramatically and the numbers more than tripled from 733 cases in 1968 to 2,574 cases in 1971. (There are
now about 6,500 cases a year.) It was then that the National Association of Black Social Workers condemned
interracial adoption citing that adoptees were at risk for developing a poor racial identity due to lack of contact with
role models of the same race. In the 1990s the placement of black children into non-black homes virtually came to a
complete stop.
Law
In 1994 the Howard M. Metzenbaum Multiethnic Placement Act was passed. It prohibits an agency that receives
Federal assistance and is involved in foster care and adoptive placements from delaying or denying the placement of
a child based on race, color, or national origin of the child or adoptive/foster parent. Then, in 1996 it was amended
with the Interethnic Adoption Provisions. These provisions forbid agencies from delaying or denying the placement
of a child solely on the basis of race and national origin. The purpose of these revisions was to strengthen compliance
and enforcement of the procedures, remove any misleading language, and demand that discrimination would not be
tolerated.
42
Another important law regarding interracial adoptions was the Adoption and Safe Families Act that was
implemented in 1997. The purpose of this law is to reduce the time that a child spends in foster care by
implementing a two-year limit and therefore hopefully moving a child closer to permanent adoption. The purpose of
this act was to reduce the instability and abuse problems in the foster care system. Critics argue that it also takes the
emphasis off of trying to keep children with their biological parents.
Academic research
Adolescent adjustment
One study found that interracial adoptees fare sometimes better, sometimes worse, but overall about the same as their
same-race adopted counterparts across the 12 adjustment measures investigated. These measures investigated indices
of academic, familial, psychological, and health outcomes for 4 groups of interracial and same-race adopted
adolescents. Specifically, interracial adoptees had significantly higher grades and significantly higher academic
expectations but marginally more distant father relationships and higher levels of psychosomatic symptoms than
their same-race adopted counterparts. Also, Asian adolescents adopted by white parents had both the highest grades
and the highest levels of psychosomatic symptoms, whereas black adolescents adopted by black parents reported the
highest levels of depression. On the other hand, black adoptees reported higher levels of self-worth than non-black
adoptees.
Appearance Discomfort
Another reported that reported adjustment problems among their children at approximately the same levels as were
reported by the parents of intraracially adopted whites. Yet, evidence also showed that extra-family forces, for
example societal racism, did negatively impact adjustment outcomes. Particularly, experiences of discrimination
generated feelings of appearance discomfort. The research suggested that black and Asian children, who appear
unmistakably different from whites, are most likely to encounter such societal discrimination. Apparently, many
Latino children with European physical features can safely escape such expressions of racism. One of this study's
most interesting findings showed that interracial adoptive parents' decisions on where to live had a substantial impact
upon their children's adjustments. Interracial adoptive parents living in predominantly white communities tended to
have adoptees that experienced more discomfort about their appearance than those who lived in integrated settings.
Cultural identity
Research has focused on the formation of cultural identity by the children adopted. For example, one study focused
on Korean and Chinese children adopted by families in the United States. Interviews discovered that a high degree of
involvement by children in Korean cultural activities was positively associated with scores measuring the strength of
the children's Korean identity as well as with ease of communication with their parents about their adoptions.
Parental encouragement of cultural activities & co-participation in them seemed to be critical in the development of
ethnic identification. Many Children find that they are so adapted to their parents' and family's culture that they start
to forget their own.
43
Ethnocentric bias
Finally, some research has examined the empirical studies of interracial adoption themselves. These studies address
whether past research that claims that interracial adoption positively benefits children of color, particularly black
children, may have methodological difficulties. Specifically, these studies analyze the presence of an ethnocentric
bias in legal and scientific assessments of childrens well-being and adjustment.
Two points of view

Pro interracial adoption
A dichotomy exists in reference to the subject of interracial adoption. Critics of race matching say there is a darker
side involving whites with lingering racist beliefs against mixing races. They argue that children are hurt most by the
practice. "One of the problems with race-matching policies," says Donna Matias, a lawyer with the Institute of
justice, "is that it leaves the children in the system to wait. They are thrown into a vicious cycle where the chances
plummet that they will ever get adopted."[3] Never getting adopted has been shown to have a negative impact on
children. After aging out of foster care, 27% of males and 10% of females were incarcerated within 12 to 18 months.
50% were unemployed, 37% had not finished high school, 33% received public assistance, and 19% of females had
given birth to children. Before leaving care, 47 percent were receiving some kind of counseling or medication for
mental health problems; that number dropped to 21% after leaving care.[4]
Pro race matching

David Watts, a biracial social worker in New York who was raised by an adoptive white family, states that "It's a bad
idea to put a black child in a white home.... I think it's impossible for someone of one culture to teach another
culture". "You have to live it in order to absorb it." The National Association of Black Social Workers (NABSW)
has taken this stance, suggesting that interracial adoption is a form of "genocide" and that "black children in white
homes are cut off from the healthy development of themselves as black people." "Same race makes sense because it
is what the child is accustomed to, what causes the least disruption in the child's life," says Toni Oliver, a chairman
of the organization. "Often when people are looking at 'love is all it takes,' they seem to overlook the impact race has
on our society. Somehow when it's a case of adoption, race suddenly doesn't seem to matter anymore."[5]
References
[1]
[2]
[3]
[4]
[5]
(http:/ / naic. acf. hhs. gov/ pubs/ s_seek. cfm)

(http:/ / www. census. gov/ prod/ 2003pubs/ censr-6. pdf)
(http:/ / library. adoption. com/ culture-and-ethnicity/ the-colors-of-adoption-black-vs-white/ article/ 1791/ 1. html)
(http:/ / statistics. adoption. com/ information/ adoption-statistics-foster-care-1999. html)
(http:/ / library. adoption. com/ culture-and-ethnicity/ the-colors-of-adoption-black-vs-white/ article/ 1791/ 1. html)
Burrow, A. L. & Finley, G. E. (2004). "Transracial, Same-Race Adoptions, and the Need for Multiple Measures
of Adolescent Adjustment," American Journal of Orthopsychiatry, 74(4), 577-583.
Courtney, M. and Piliavin, I. (1998). "In Struggling in the Adult World," The Washington Post, July 21, 1998.
Study conducted by School of Social Work, University of WisconsinMadison.
Feigelman, W. (2000). "Adjustments of transracially and inracially adopted young adults," Child and Adolescent
Social Work Journal, 17(3), 165-183.
Grob (2003). "International Adoption: The Relationship between Child and Parent Characteristics and Parent
Report of Child Adjustment," Dissertation Abstracts International. A, The humanities and social sciences, 64(4).
Huh, N. S. & Reid, W. J. (2000). "Intercountry, Transracial Adoption and Ethnic Identity," International Social
Work, 43(1), 75-87.
44
External links
Adoption Services Worldwide (http://www.babyasw.com/international-adoption/adoption-inquiry.php)
Interracially/ Bi-Racial Adoptions]
Adoption.com (http://library.adoption.com/)
Adoption History (http://www.adoptionhistory.org/)
AICAN - Australian Intercountry Adoption Network (http://www.aican.org/)
Asian-Nation (http://www.asian-nation.org/adopted.shtml) Interracially Adopted Asian Americans]
Raising Katie What adopting a white girl taught a black family about race in the Obama era (http://www.
newsweek.com/id/194886)
Embryo donation
Embryo donation is a form of third party reproduction. It is defined as the givinggenerally without
compensationof embryos remaining after one couple's In vitro fertilisation, or IVF treatments, to another person or
couple, followed by the placement of those embryos into the recipient woman's uterus to facilitate pregnancy and
childbirth in the recipient. Most often, the embryos are donated after the woman for whom they were originally
created has successfully carried one or more pregnancies to term. The resulting child is considered the child of the
woman who carries it and gives birth, and not the child of the donor. This is the same principle as is followed in egg
donation or sperm donation.
Embryo donation can be handled on an anonymous basis (donor and recipient parties are not known to each other),
or on an open basis (parties' identities are shared and the families agree to a relationship. Occasionally, a
"semi-open" arrangement is used in which the parties know family and other information about each other, but their
real names and locating information are withheld, in order to provide a layer of privacy protection. Some writers use
the term "embryo donation" to refer strictly to anonymous embryo donation, and "embryo adoption" to refer to the
open process.[1] Others use the terms synonymously because regardless of whether the arrangement is open or
anonymous, the donation of embryos and a clinical assisted reproduction procedure is involved, and the recipient
couple is preparing to raise a child not genetically related to them.[2]
In the United States, those donating embryos must, if possible, be screened for a series of infectious diseases.[3] The
rules for screening are outlined by the U.S. Food and Drug Administration (FDA). If the donors are not available to
be screened, the embryos must be given a label that indicates that the required screening has not been done, and the
recipients must agree to accept the associated risk. The amount of screening the embryo has already undergone is
largely dependent on the genetic parents' own IVF clinic and process. The embryo recipient may elect to have her
own embryologist conduct further testing.
Alternatives to donating remaining embryos are: discarding them (or having them implanted at a time when
pregnancy is very unlikely,[4] or donating them for use in embryonic stem cell research. Although embryos can,
theoretically, survive indefinitely in frozen storage, as a practical reality someone must eventually decide on a
permanent disposition for them.
A US study concluded that embryo donation is approximately twice as cost-effective as oocyte donation in terms of
cost per live birth, with a cost of $22,000 per live delivery compared to $41,000 for oocyte donation .
45
Embryo donation
History
Not long after IVF came into common clinical practice, clinicians discovered a way to maintain (cryopreserve)
embryos in frozen storage and thaw them once again for implantation later, thus, in some cases sparing the woman a
second egg harvesting procedure,.[5] [6]
At about the same time, clinicians reasoned that more couples could be helped toward parenthood by substituting
donor sperm for men who have no viable sperm, or donor eggs for women who have no viable oocytes or both.
Thus what was called gamete and embryo donation, came into being. A careful reading of the 1983 clinical report
often cited as the first instance of embryo donation reveals that the donated embryo was actually created for the
recipient at the same time that four embryos were made for the donor couples own use. The menstrual cycles of the
donor and recipient women were synchronized using medications, and the transfers occurred on the same day. None
of these embryos had been cryopreserved.
Soon thereafter, reports were published documenting successful pregnancies and births from cryopreserved donor
embryos. Again, however, these were embryos made from donor gametes specifically for the recipients.[7] [8]
No one knows for sure when the first true embryo adoption occurred. The term was used as early as the
mid-1980s,[9] [10] in the legal literature. Devroey et al.,[11] Dr. Maria Bustillo in Florida, and Dr. Howard Jones in
Virginia have reported embryo transfers occurring between 1986 and 1990 that clearly represented adoption of
remaining embryos.
Prior to this, thousands of women who were infertile had regarded adoption as the only available path to parenthood.
These scientific advances set the stage to allow open and candid discussion of embryo donation and transfer as a
solution to infertility. In some ways, it is similar to other donations such as blood and major organ donations. Some
see the embryo as "tissue", others see it as a "gift of a potential life",[12] while still others believe that a new human
life begins at the time of fertilization. The third group sees embryo donation as little different from traditional
adoption, except that the recipient woman has the experience of pregnancy and childbirth, and that no court action is
required to establish legal parentage for the recipient.
The matter gained another political dimension in the United States when Congress and the Bush administration gave
$1 million to promote embryo adoption.[13]
Process
Embryo donation is legally considered a property transfer and not an adoption by state laws. However, Georgia
enacted a statute called the Option of Adoption Act" in 2009 which provided a procedure for, but (importantly) did
not requirea confirmatory court order of parentage following embryo adoption.[14] One advantage some embryo
adoption couples in Georgia have derived from this law is that they have become eligible for the federal Adoption
Tax Credit.
Embryo donation can be carried out as a service of an individual infertility clinic (where donor and recipient families
typically live in the local area and are both patients of the same clinic) or by any of several national organizations.
The process described below is typical of an "adoption-agency-based" national program:
Genetic parents entering an embryo adoption program are offered the benefits of selecting the adoptive parents from
the agency's pool of prescreened applicants. Embryo ownership is transferred directly from the genetic parents to the
adoptive parents. Genetic parents may be updated by the agency when a successful pregnancy is achieved and when
a child(ren) is/are born. The genetic parents and adoptive parents may negotiate their own terms for future contact
between the families.
Prospective adoptive parents entering a program complete an application, traditional adoption home study, adoption
education, health checks and in some cases, depending on the requirements of both the home study and placement
agencies, court certification of adoption eligibility. Their completed paperwork and fees are submitted to the
placement agency, which reviews their file and matches them to genetic parents with similar preferences including
46
Embryo donation
desired level of openness post-adoption. Genetic and prospective parents are then given the chance to approve the
match. Once all parties agree, the embryo is transferred to the adoptive mother's clinic for a frozen embryo transfer.
None of the procedures involved with embryo adoption by either the genetic or adopting parents are legal
requirements of embryo transfer. The process is entered in to willingly by both sets of parents because of the added
safeguards, knowledge and communication offered to both parties by the system.[15] The Snowflakes Embryo
Adoption Program refers to the uniqueness of each embryo. Because Nightlight Christian Adoptions was the first to
publicize the option nationally and, for several years, handled most cases in which families were matched outside the
confines of an individual clinic, the term "Snowflake Babies" has become common vernacular when referring to the
embryo-adoption process, though no longer referring exclusively to Nightlight's Snowflake Embryo Adoption
Program.
As of July, 2011, Nightlight has reported 271 children born through the embryo adoption program. Concurrently, the
National Embryo Donation Center [16] (NEDC) reports 280 born through their program since its inception in 2003.
Located in Knoxville, Tennessee, NEDC is the nation's only clinic-based, non-profit, national embryo donation
entity. Its primary difference from Nightlight and other adoption-agency-based programs is that the clinical services,
rather than being performed at a separate infertility clinic, are performed at the NEDC facility in Knoxville. This
allows the family to receive all the services in a comprehensive manner at one location under the guidance of a
trained coordinator. The only exception is the home study, as described above. The Embryo Donation Services of
Cedar Park, located near Seattle, Washington (www.adoptanembryo.net) is the nation's only church-based embryo
adoption enterprise. Founded by an embryo adoption mother, it operates on principles similar to the Snowflake
Program [17].
Several other agencies nationwide offer embryo donation services, including Embryos Alive [18], Bethany Christian
Services [19] , and Crystal Angels [20].
References
[1] Snowflake Program, Nightlight Christian Adoptions
[2] National Embryo Donation Center
[3] http:/ / www. fda. gov/ BiologicsBloodVaccines/ TissueTissueProducts/ QuestionsaboutTissues/ ucm136397. htmhttp:/ / www.
miracleswaiting. org/ explorembryo. html
[4] Finger R, Sommerfelt C, Freeman M, Wilson CK, Wade A, Daly D (April 2009). "A cost-effectiveness comparison of embryo donation with
oocyte donation". Fertil. Steril. 93 (2): 379381. doi:10.1016/j.fertnstert.2009.03.019. PMID 19406398.
[5] Trounson A, Freemann L. The use of embryo cryopreservation in human IVF programmes. Clin Obstet Gynaecol 1985 Dec;12(4):825-33
[6] Downing BG, Mohr LR, Trounson AO, Freemann LE, Wood C. Birth After Transfer of Cryopreserved Embryos. Med J Aust 1985 Apr
1;142(7):409-11
[7] Sauer MV, Paulson RJ. Human Oocyte and Preembryo Donation: an Evolving Method for the Treatment of Infertility. Am J Obstet Gynecol
1990 Nov;163(5 Pt 1):1421-1424
[8] Van Steirteghem AC, Van den Abbeel E, Braeckmans P, et al. Pregnancy With a Frozen-thawed Embryo in a Woman With Primary Ovarian
Failure. NEJM 1987; 317:113
[9] Robertson JA. Embryos, Families, and Procreative Liberty: the Legal Structure of the New Reproduction. Southern California Law Review.
1986. 59: 939-1041
[10] Wurmbrand MJ. Frozen embryos: moral, social, and legal implications. South Calif Law Rev 1986 Jul;59(5):1079-1100
[11] Devroey P, Camus M, van den Abbeel E, van Waesberghe L, Wisanto A, van Steirteghem AC. Establishment of 22 Pregnancies After
Oocyte and Embryo Donation. Br J Obstet Gynaecol 1989 Aug;96(8):900-906
[12] National Embryo Donation Center: Questionnaire Study of Prospective Embryo Donors
[13] The White House. President Discusses Stem Cell Research. Office of the Press Secretary, August 9, 2001. http:/ / georgewbush-whitehouse.
archives. gov/ news/ releases/ 2001/ 08/ 20010809-2. html
[14] http:/ / www. gainesvilletimes. com/ news/ archive/ 20665/
[15] Embryo Adoption & Donation
[16] http:/ / www. embryodonation. org/
[17]
[18]
[19]
[20]
http:/ / www. adoptanembryo. net

http:/ / www. embryosalive. com/
http:/ / www. bethany. org/ main/ embryo-services
http:/ / www. childrensconnections. org/ crystal_angels. htm
47
Foster care
Foster care
Foster care is the term used for a system in which a minor who has been made a ward is placed in the private home
of a state certified caregiver referred to as a "foster parent".
The state via the family court and child protection agency stand in loco parentis to the minor, making all legal
decisions while the foster parent is responsible for the day to day care of said minor. The foster parent is remunerated
by the state for their services.
Foster care is intended to be a short term situation until a permanent placement can be made:[1]
Reunification with the biological parent(s)
When it is deemed in the child's best interest. This is generally the first choice.
Adoption
Preferably by a biological family member such as an aunt or grandparent.
If no biological family member is willing or able to adopt, the next preference is for the child to be adopted by
the foster parents or by someone else involved in the child's life (such as a teacher or coach). This is to
maintain continuity in the child's life.
If neither above option are available, the child may be adopted by someone who is a stranger to the child.
Permanent transfer of guardianship
If none of these options are viable the plan for the minor may enter OPPLA (Other Planned Permanent Living
Arrangement). This option allows the child to stay in custody of the state and the child can stay placed in a foster
home, with a relative or an Independent Living Center or long term care facility (for children with development
disabilities, physical disabilities or mental disabilities).
Foster care placement

547,415 children were in publicly supported foster care in the United States in September 2000.[2] In 2009, there
were 423,773 children in foster care, a drop of about 20% in a decade.[3]
In 2009, there were about 123,000 children ready for adoptive families in the nations foster care systems.[4] African
American children represented 41% of children in foster care, white children represented 40% and Hispanic children
represented 15% in the year 2000.[2]
Children may enter foster care via voluntary or involuntary means. Voluntary placement may occur when a
biological parent or lawful guardian is unable or unwilling to care for a child. Involuntary placement occurs when a
child is removed from their biological parent or lawful guardian due to the risk or actual occurrence of physical or
psychological harm. In the US, most children enter foster care due to neglect.[5]
Regulation, administration, and oversight

The policies regarding foster care as well as the criteria to be met in order to become a foster parent vary according
to legal jurisdiction.
In the United States, foster home licensing requirements vary from state to state but are generally overseen by each
state's Department of Social Services or Human Services. In some states, counties have this responsibility. Each
state's services are monitored by the federal Department of Health and Human Services through reviews such as
Child and Family Services Reviews, Title IV-E Foster Care Eligibility Reviews, Adoption and Foster Care Analysis
and Reporting System and Statewide Automated Child Welfare Information System Assessment Reviews.[6]
The foster parent licensing process is often similar to the process to become licensed to adopt. It requires preparation
classes as well as an application process. The application varies but may include: a minimum age, verification that
your income allows you to meet your expenses, a criminal record check at local, state and federal levels including
48
Foster care
49
finger printing and no prior record of child abuse or neglect; a reference from a doctor to ensure that all household
members are free from diseases that a child could catch and in sufficient health to parent a child and; letters of
reference from an employer and others who know them.
Children found to be unable to function in a foster home may be placed in Residential Treatment Centers (RTCs) or
other such group homes. In theory, the focus of treatment in such facilities is to prepare the child for a return to a
foster home, to an adoptive home, or to the birth parents when applicable. But two major reviews of the scholarly
literature have questioned these facilities' effectiveness.[7] There are some children in foster care who are difficult to
place in permanent homes through the normal adoption process. These children are often said to require
special-needs adoption. In this context, "special needs" can include situations where children have specific chronic
medical problems, mental health issues, behavioral problems, and learning disabilities. In some cases, sibling groups,
and older children qualify as "special needs."[8] Governments offer a variety of incentives and services to facilitate
this class of adoptions.[9]
Funding and system incentives
A law passed by Congress in 1961 allowed AFDC (welfare) payments to pay for foster care which was previously
made only to children in their own homes. This made aided funding foster care for states and localities, facilitating
rapid growth. In some cases, the state of Texas paid mental treatment centers as much as $101,105 a year per child.
Observers of the growth trend note that a county will only continue to receive funding while it keeps the child in its
care. This may create a "perverse financial incentive" to place and retain children in foster care rather than leave
them with their parents, and incentives are sometimes set up for maximum intervention. A National Coalition for
Child Protection Reform issue paper states "children often are removed from their families `prematurely or
unnecessarily' because federal aid formulas give states `a strong financial incentive' to do so rather than provide
services to keep families together."[10]
Findings of a grand jury investigation in Santa Clara, California:[11]
The Grand Jury heard from staff members of the DFCS and others outside the department that the department
puts too much money into "back-end services," i.e., therapists and attorneys, and not enough money into
"front-end" or basic services. The county does not receive as much in federal funds for "front-end" services,
which could help solve the problems causing family inadequacies, as it receives for out-of-home placements or
foster care services. In other words, the Agency benefits, financially, from placing children in foster homes.
Foster care
50
United States
Foster care legislation since 1990
In 1997, the Adoption and Safe Families Act
(ASFA) was passed.[12] This reduced the
time children are allowed to remain in foster
care before being available for adoption.
The new law requires state child welfare
agencies to identify cases where "aggravated
circumstances" make permanent separation
of child from the birth family the best option
for the safety and well-being of the child.
One of the main components of ASFA is the
imposition of stricter time limits on
reunification efforts. Proponents of ASFA
claimed that before the law was passed, the
lack of such legislation was the reason it
was common for children to languish in care
for years with no permanent living situation
identified.
Average length of stay in foster care in the U.S.
Opponents of ASFA argued that the real reason children languished in foster care was that too many were taken
needlessly from their parents in the first place. Since ASFA did not address this, opponents said, it would not
accomplish its goals, and would only slow a decline in the foster care population that should have occurred anyway
because of a decline in reported child abuse.[13]
Ten years after ASFA became law, the number of children in foster care on any given day has been about 7,000
fewer than when ASFA was passed[14]
The Foster Care Independence Act of 1999, helps foster youth who are aging out of care to achieve self-sufficiency.
The U.S. government has also funded the Education and Training Voucher Program in recent years in order to help
youth who age out of care to obtain college or vocational training at a free or reduced cost. Chafee and ETV money
is administered by each state as they see fit.
The Fostering Connections to Success and Increasing Adoptions Act of 2008 is the most recent piece of major
federal legislation addressing the foster care system. This bill extended various benefits and funding for foster
children between the age of 18 and 21 and for Indian children in tribal areas. The legislation also strengthens
requirements for states in their treatment of siblings and introduces mechanisms to provide financial incentives for
guardianship and adoption.[15] [16]
Constitutional issues
In May 2007, the United States 9th Circuit Court of Appeals found in ROGERS v. COUNTY OF SAN JOAQUIN,
No. 05-16071[17] that a CPS social worker who removed children from their natural parents into foster care without
obtaining judicial authorization, was acting without due process and without exigency (emergency conditions)
violated the 14th Amendment and Title 42 United State Code Section 1983. The Fourteenth Amendment to the
United States Constitution says that a state may not make a law that abridges "... the privileges or immunities of
citizens of the United States" and no state may "deprive any person of life, liberty, or property, without due process
of law; nor deny to any person within its jurisdiction the equal protection of the laws." Title 42 United States Code
Section 1983[18] states that citizens can sue in federal courts any person that acting under a color of law to deprive
Foster care
the citizens of their civil rights under the pretext of a regulation of a state.[19]
In case of Santosky v. Kramer, 455 US 745, Supreme Court reviewed a case when Department of Social Services
removed two younger children from their natural parents only because the parents had been previously found
negligent toward their oldest daughter.[20] When the third child was only three days old, DSS transferred him to a
foster home on the ground that immediate removal was necessary to avoid imminent danger to his life or health. The
Supreme Court vacated previous judgment and stated: "Before a State may sever completely and irrevocably the
rights of parents in their natural child, due process requires that the State support its allegations by at least clear and
convincing evidence. <..> But until the State proves parental unfitness, the child and his parents share a vital interest
in preventing erroneous termination of their natural relationship".[20]
Also District of Columbia Court of Appeals conclude that the lower trial court erred in rejecting the relative
custodial arrangement selected by the natural mother who tried to preserve her relationship with the child.[21] The
previous judgment granting the foster mother's adoption petition was reversed, and the case remanded to the trial
court to vacate the orders granting adoption and denying custody, and to enter an order granting custody to the
child's relative.[21]
In 2007 Deanna Fogarty-Hardwick obtained a jury verdict against Orange County (California) and two of its social
workers for violating her Fourteenth Amendment rights to familial association by unlawfully placing her kids in
foster care.[22] The $4.9 million verdict grew to a $9.5 million judgment as the County lost each of its successive
appeals.[22] The case finally ended in 2011 when the United States Supreme Court denied Orange County's request
to overturn the verdict.[23]
Australia
Home-based care, which includes foster care, is provided to children who are in need of care and protection.
Children and young people are provided with alternative accommodation while they are unable to live with their
parents. As well as foster care, this can include placements with relatives or kin, and residential care. In most cases,
children in home-based care are also on a care and protection order.[24]
In some cases children are placed in home-based care following a child protection substantiation and where they are
found to be in need of a safer and more stable environment. In other situations parents may be incapable of providing
adequate care for the child, or accommodation may be needed during times of family conflict or crisis.[24] In the
significant number of cases substance abuse is a major contributing factor.
Respite care is a type of foster care that is used to provide short-term (and often regular) accommodation for children
whose parents are ill or unable to care for them on a temporary basis.[24] It is also used to provide a break for the
parent or primary carer to hopefully decrease the chances of the situation escalating to one which would lead to the
removal of the child(ren).
As with the majority of child protection services, states and territories are responsible for funding home-based care.
Non-government organizations are widely used, however, to provide these services.[24]
Current policy
There is strong emphasis in current Australian policy and practice to keep children with their families wherever
possible. In the event that children are placed in home-based care, every effort is made to reunite children with their
families wherever possible.[24]
In the case of Aboriginal and Torres Strait Islander children in particular, but not exclusively, placing the child
within the wider family or community is preferred[24] This is consistent with the Aboriginal Child Placement
Principle.[25]
51
Foster care
The negative effects of foster care

Individuals who were in foster care experience higher rates of physical and psychiatric morbidity than the general
population and suffer from not being able to trust and that can lead to placements breaking down.[26] In a study of
adults who were in foster care in Oregon and Washington state, they were found to have double the incidence of
depression, 20% as compared to 10% and were found to have a higher rate of post-traumatic stress disorder (PTSD)
than combat veterans with 25% of those studied having PTSD. Children in foster care have a higher probability of
having Attention Deficit Hyperactivity Disorder, and deficits in executive functioning, anxiety as well other
developmental problems.[27] [28] [29] [30] These children experience higher degrees of incarceration, poverty,
homelessness, and suicide. Recent studies in the U.S. suggest that foster care placements are more detrimental to
children than remaining in a troubled home.[31] [32] [33]
Neurodevelopment
Foster care has been shown in various studies to have deleterious consequences on the physical health and mental
wellbeing of those who were in foster care. Many children enter foster care at a very young age, a period where the
development of mental and psychological processes are at one of their critical peaks. The human brain doesn't fully
develop until approximately the age of twenty, and one of the most critical periods of brain development occurs in
the first 34 years. The processes that govern the development of personality traits, stress response and cognitive
skills are formed during this period. The developing brain is directly influenced by negative environmental factors
including lack of stimulation due to emotional neglect, poor nutrition, exposure to violence in the home environment
and child abuse.
Negative environmental influences have a direct effect on all areas of neurodevelopment: neurogenesis (creation of
new neurons), apoptosis (death and reabsorption of neurons), migration (of neurons to different regions of the brain),
synaptogenesis (creation of synapses), synaptic sculpturing (determining the make-up of the synapse), arborization
(the growth of dendritic connections, myelinzation (protective covering of neurons), and an enlargement of the
brain's ventricles, which can cause cortical atrophy.
Most of the processes involved in healthy neurodevelopment are predicated upon the establishment of close
nurturing relationships and environmental stimulation. Foster children have elevated levels of cortisol, a stress
hormone in comparison to children raised by their biological parents. Elevated cortisol levels can compromise the
immune system. (Harden BJ, 2004).[34] Negative environmental influences during this critical period of brain
development can have lifelong consequences.[35] [36] [37] [38]
Epigenetic effects of environment

Gene expression can be affected by the environment through epigenetic mechanisms. Negative environmental
influences, such as maternal deprivation, child abuse and stress[39] [40] have been shown to have a profound effect on
gene expression, including transgenerational epigenetic effects in which physiological and behavioral (intellectual)
transfer of information across generations-not-yet-conceived is effected. In the verkalix study in Sweden, the
effects of epigentic inheritance were shown to have a direct correlation to the environmental influences faced by the
parents and grandparents.[41] Many physiological and behavioral characteristics ascribed to Mendelian inheritance
are due in fact to transgenerational epigenetic inheritance. The implications in terms of foster care and the cost to
society as a whole is that the stress, deprivation and other negative environmetal factors many foster children are
subjected to has a detrimental effect not only their physical, emotional and cognitive well-being, but that the damage
can transcend generations.[42] [43] [44]
In studies of the adult offspring of Holocaust survivors, parental PTSD was a risk factor for the development of
PTSD in adult offspring in comparison to those whose parents went through the Holocaust without developing
PTSD. The offspring of survivors with PTSD had lower levels of urinary cortisol excretion, salivary cortisol and
enhanced plasma cortisol suppression in response to low dose dexamethasone administration than offspring of
52
Foster care
53
survivors without PTSD. Low cortisol levels are associated with parental, particularly maternal, PTSD. This is in
contrast to the normal stress response in which cortisol levels are elevated after exposure to a stressor. The results of
the study point to the involvement of epigenetic mechanisms.[45] [46]
Epigenetic Effects of Abuse
"In addition, the effects of abuse may extend beyond the immediate victim into subsequent generations as a consequence of epigenetic effects
[47]
transmitted directly to offspring and/or behavioral changes in affected individuals. (Neighh GN et al. 2009)
It has been suggested in various studies that the deleterious epigentic effects may be somewhat ameliorated through
pharmacological manipulations in adulthood via the administration of nerve growth factor-inducible protein A,[48]
and through the inhibition of a class of enzymes known as the histone deacetylases (HDACs). "HDAC inhibitors
(HDACIs) such as Trichostatin A (TSA); "TSA can be used to alter gene expression by interfering with the removal
of acetyl groups from histones", and L-methionine an essential amino acid, have been developed for the treatment of
a variety of malignancies and neurodegenerative disorders. Drug combination approaches have also shown promise
for the treatment of mood disorders including bipolar disorder, anxiety and depression."[49] [50]
Post traumatic stress disorder

Children in foster care have a higher
incidence of Post traumatic stress disorder
(PTSD).In one study (Dubner and Motta,
1999)[52] 60% of children in foster care who
had experienced sexual abuse had PTSD,
and 42% of those who had been physically
abused fulfilled the PTSD criteria. PTSD
was also found in 18% of the children who
were not abused. These children may have
developed PTSD due to witnessing violence
in the home. (Marsenich, 2002).
In a study conducted in Oregon and
Washington state, the rate of PTSD in adults
who were in foster care for one year
between the ages of 14-18 was found to be
higher than that of combat veterans, with 25
percent of those in the study meeting the
diagnostic criteria as compared to 12-13
[51]
Regions of the brain associated with stress and post traumatic stress disorder
percent of Iraq war veterans and 15 percent
of Vietnam war veterans, and a rate of 4% in
the general population. The recovery rate for foster home alumni was 28.2% as opposed to 47% in the general
population.
"More than half the study participants reported clinical levels of mental illness, compared to less than a quarter of the
general population".[53] [54]
Foster care
Eating disorders
Foster children are at increased risk for a variety of eating disorders, in comparison to the general population.
Obesity children in foster care are more prone to becoming overweight and obese, and in a study done in the United
Kingdom, 35% of foster children experienced an increase in Body Mass Index (BMI) once in care.[55]
Hyperphagic Short Stature syndrome (HSS) is a condition characterized by short stature due to insufficient
growth hormone production, an excessive appetite (hyperphagia) and mild learning disabilities. While it is believed
to have genetic component, HSS is triggered by being exposed to an environment of high psychosocial stress; it is
not uncommon in children in foster homes or other stressful environments. HSS improves upon removal from the
stressful environment.[56] [57] [58]
Food Maintenance Syndrome is characterized by a set of aberrant eating behaviors of children in foster care. It is
"a pattern of excessive eating and food acquisition and maintenance behaviors without concurrent obesity"; it
resembles "the behavioral correlates of Hyperphagic Short Stature". It is hypothesised that this syndrome is triggered
by the stress and maltreatment foster children are subjected to, it was prevalent amongst 25 percent of the study
group in New Zealand.[28]
Bulimia Nervosa is seven times more prevalent among former foster children than in the general population.[59]
Disorganized attachment
A study by Dante Cicchetti found that 80% of abused and maltreated infants in his study exhibited symptoms of
disorganized attachment.[60] [61] Children with histories of maltreatment, such as physical and psychological neglect,
physical abuse, and sexual abuse, are at risk of developing psychiatric problems.[62] [63] [64] [65] These children may
be described as experiencing trauma as the result of abuse or neglect, inflicted by a primary caregiver, which disrupts
the normal development of secure attachment. Such children are at risk of developing a disorganized attachment.[64]
[66] [67]
Disorganized attachment is associated with a number of developmental problems, including dissociative
symptoms,[68] as well as depressive, anxiety, and acting-out symptoms.[69] [70]
Child abuse
Children in foster care experience high rates of child abuse, emotional deprivation, and physical neglect. In one
study in the United Kingdom "foster children were 7-8 times, and children in residential care 6 times more likely to
be assessed by a pediatrician for abuse than a child in the general population".[71]
Poverty and homelessness

Nearly half of foster kids in the U.S. become homeless when they turn
18.[72] [73] "One of every 10 foster children stays in foster care longer
than seven years, and each year about 15,000 reach the age of majority
and leave foster care without a permanent familymany to join the
ranks of the homeless or to commit crimes and be imprisoned.[74] [75]
Three out of 10 of the United States homeless are former foster
children.[76] According to the results of the Casey Family Study of
Foster Care Alumni, up to 80 percent are doing poorlywith a quarter
to a third of former foster children at or below the poverty line, three
New York street children; 1890
times the national poverty rate.[77] Very frequently, people who are
homeless had multiple placements as children: some were in foster
care, but others experienced "unofficial" placements in the homes of family or friends.
54
Foster care
55
Individuals with a history foster care tend to become homeless at an earlier age than those who were not in foster
care and Caucasians who become homeless are more likely to have a history of foster care than Hispanics or African
Americans . The length of time a person remains homeless is prolonged in indiviuals who were in foster care.[78]
Suicide-death rate
Children in foster care are at a greater risk of suicide,[79] the increased risk of suicide is still prevalent after leaving
foster care and occurs at a higher rate than the general population. In a small study of twenty-two Texan youths who
aged out of the system, 23 percent had a history of suicide attempts.[80]
A Swedish study utilizing the data of almost one million people including 22,305 former foster children who had
been in care prior to their teens, concluded:
Former child welfare clients were in year of birth and sex standardised risk ratios (RRs) four to five times
more likely than peers in the general population to have been hospitalised for suicide attempts....Individuals
who had been in long-term foster care tended to have the most dismal outcome...former child
welfare/protection clients should be considered a high-risk group for suicide attempts and severe psychiatric
morbidity.[81]
Death rate
Children in foster care have an overall higher mortality rate than children in the general population.[82] A study
conducted in Finland among current and former foster children up to age 24 found a higher mortality rate due to
substance abuse, accidents, suicide and illness. The deaths due to illness were attributed to an increased incidence of
acute and chronic medical conditions and developmental delays among children in foster care.[83]
Georgia Senator Nancy Schaefer published a report "The Corrupt Business of Child Protective Services"[84] stating:
"The National Center on Child Abuse and Neglect in 1998 reported that six times as many children died
in foster care than in the general public and that once removed to official safety, these children are far
more likely to suffer abuse, including sexual molestation than in the general population".[84]
Poor academic prospects

[85]
Educational outcomes of ex-foster children in the Northwest Alumni Study*
56% completed high school compared to 82% of the general population, although an additional 29% of former foster children received a G.E.D.
compared to an additional 5% of the general population.
42.7% completed some education beyond high school.
20.6% completed any degree or certificate beyond high school
16.1% completed a vocational degree; 21.9% for those over 25.
1.8% complete a bachelors degree, 2.7% for over 25, the completion rate for the general population in the same age group is 24%, a sizable
difference.
*The study reviewed case records for 659 foster care alumni in Northwest USA, and interviewed 479 of them between September 2000 and January
[85]
2002.
Several studies have indicated that foster care children tend to underachieve academically with many never
completing high school. In a study conducted in Philadelphia by Johns Hopkins University it was found that; among
high school students who are in foster care, have been abused and neglected, or receive out of home placement by
the courts, the probability of dropping out of school is greater than 75%.[86]
Foster care
56
State abuses in the United States

Drug testing
Throughout the 1990s, experimental HIV drugs were tested on HIV-positive foster children at Incarnation Childrens
Center in Harlem. The agency has also been accused of racism, some comparing the trials to the Tuskegee syphilis
experiment, as 98 percent of children in foster care in New York City belong to ethnic minorities.[87]
Unnecessary/over medication
Studies[88] have revealed that youth in foster care covered by Medicaid insurance receive psychotropic medication at
a rate that was 3 times higher than that of Medicaid-insured youth who qualify by low family income. In a review
(September 2003 to August 2004) of the medical records of 32,135 Texas foster care 019 years-old, 12,189 were
prescribed psychotropic medication, resulting in an annual prevalence of 37.9% of these children being prescribed
medication. 41.3% received 3 different classes of these drugs during July 2004, and 15.9% received 4 different
classes. The most frequently used medications were antidepressants (56.8%), attention-deficit/hyperactivity disorder
drugs (55.9%), and antipsychotic agents (53.2%).
"Concomitant psychotropic medication treatment is frequent for youth in foster care and lacks substantive
evidence as to its effectiveness and safety".[88]
Psychotropic medication patterns among youth in foster care., Pediatrics 2008
Psychiatrists prescribed 93% of the psychotropic medication, and it was noted in the review of these cases that the
use of expensive, brand name, patent protected medication was prevalent. In the case of SSRIs the use of the most
expensive medications was noted to be 74%, in the general market only 28% are for brand name SSRI's vs generics.
The average out-of-pocket expense per prescription was $34.75 for generics and $90.17 for branded products, a
$55.42, difference.[89]
Sexual abuse and negligence

One study by Johns Hopkins University found that the rate of sexual abuse within the foster-care system is more than
four times as high as in the general population; in group homes, the rate of sexual abuse is more than 28 times that of
the general population.[90] [91] An Indiana study found three times more physical abuse and twice the rate of sexual
abuse in foster homes than in the general population.[91] A study of foster children in Oregon and Washington State
found that nearly one third reported being abused by a foster parent or another adult in a foster home.[92] These
statistics do not speak to the situation these children are coming from, but it does show the very large problem of
child-on-child sexual abuse within the system. There have been several notable lawsits concerning sexual abuse and
negligence that caused review of the foster care system in some states:
In 2010, an ex-foster child was awarded $30 million by jury trial in California (Santa Clara County) for sexual abuse
damages that happened to him in his foster home from 1995 to 1999.[93] [94] The foster parent, John Jackson, was
licensed by the state, despite the fact that he abused his own wife and son, overdosed on drugs and was arrested for
drunken driving. In 2006, Jackson was convicted in Santa Clara County of nine counts of lewd or lascivious acts on
a child by force, violence, duress, menace and fear, and seven counts of lewd or lascivious acts on a child under 14,
according to the Santa Clara County District Attorney's Office.[93] The sex acts he forced the children in his foster
care to perform sent him to prison for 220 years. Later in 2010, Giarretto Institute, the private foster family agency
responsible for licensing and monitoring Jackson's foster home and others, also was found to be negligent and liable
for 75 percent of the abuse that was inflicted on the victim, and Jackson himself was liable for the rest.[93]
In 2009, Oregon Department of Human Services agreed to pay $2 million into a fund for the future care of twins
who were allegedly abused by their foster parents; this was the largest such settlement in the agency's history.[95]
According to the civil rights suit filed on request of twins' adoptive mother in December 2007 in U.S. Federal Court,
Foster care
the children were kept in makeshift cagescribs covered with chicken wire secured by duct tapein a darkened
bedroom known as "the dungeon." The brother and sister often went without food, water or human touch. The boy,
who had a shunt put into his head at birth to drain fluid, didn't receive medical attention, so when police rescued the
twins he was nearly comatose. The same foster family previously took into their care hundreds of other children over
nearly four decades.[96] DHS said the foster parents deceived child welfare workers during the checkup visits.[95]
Several lawsuits were brought in 2008 against the Florida Department of Children & Families (DCF), accusing it of
mishandling reports that Thomas Ferrara, 79, a foster parent, was molesting young girls.[97] [98] The suits claimed
that even though there were records of sexual misconduct allegations against Ferrara in 1992, 1996, and 1999, the
DCF continued to place foster children with Ferrara and his then-wife until 2000.[97] Ferrara was arrested in 2001,
after a 9-year-old girl told detectives he regularly molested her over two years and threatened to hurt her mother if
she told anyone. Records show that Ferrara had as many as 400 children go through his home during his 16 years as
a licensed foster parent (from 1984 to 2000).[97] Officials stated that the lawsuits over Ferrara ended up costing the
DCF almost $2.26 million.[98] Similary, in 2007 Florida's DCF paid $1.2 million to settle a lawsuit that alleged DCF
ignored complaints that another mentally disabled Immokalee girl was being raped by her foster father, Bonifacio
Velazquez, until the 15-year-old gave birth to a child.[99] [100] [101]
In a class action lawsuit Charlie and Nadine H. v. McGreevey[102] was filed in federal court by "Childrens Rights"
New York organization on behalf of children in the custody of the New Jersey Division of Youth and Family
Services (DYFS).[103] [104] The complaint alleged violations of the childrens' constitutional rights and their rights
under Title IV-E of the Social Security Act, the Child Abuse Prevention and Treatment Act, Early Periodic
Screening Diagnosis and Treatment, 504 of the Rehabilitation Act, the Americans with Disabilities Act, and the
Multiethnic Placement Act (MEPA).[105] In July 2002, the federal court granted plaintiffs experts access to 500
childrens case files, allowing plaintiffs to collect information concerning harm to children in foster care through a
case record review.[103] These files revealed numerous cases in which foster children were abused, and DYFS failed
to take proper action. On June 9, 2004, the child welfare panel appointed by the parties approved the NJ States
Reform Plan. The court accepted the plan on June 17, 2004.[104] The same organization also filed similar lawsuits
against several other states in recent years that caused some of the states to start child welfare reforms.[106]
Strip Searches
Sometimes children who have been taken from their homes due to abuse or neglect are temporarily placed into
shelters if a foster home is not immediately available. Some of these shelters are wings of juvenile detention
facilities. Sometimes the foster children placed into these shelter wings are subjected to strip searches similar to
those performed on juvenile offenders. [107]
The lost children (Australia)

An estimated 150,000 British children were sent to overseas colonies and countries in the commonwealth such as
Australia. This practice was in effect from the beginning of the nineteenth century until 1967. Many of these children
were sent to orphanages, foster homes and religious institutions, where they were used as a free source of labour and
many were severely abused and neglected. These children were classified as orphans although most were not. In the
period after World War II the policy was dubbed the "Child Migrants Programme". The prime consideration was
money as it was cheaper to care for children in commonwealth countries than it was in the United Kingdom. At least
10,000 children, some as young as 3, were shipped to Australia after the war,[108] [109] most to join the ranks of the
"Forgotten Australians", the term given for those who experienced care in foster homes and institutions in the 20th
century. Among these Forgotten Australians were members of the "Stolen Generation", the children of Australian
Aborigines, forcibly removed from their homes and raised in white institutions. In 2008 Australian Prime Minister,
Kevin Rudd apologised to the approximately 500,000 "forgotten Australians" and in 2010 British Prime Minister
Gordon Brown issued a similar apology to those who were victimised by the Child Migrants Programme.[110] [111]
57
Foster care
[112]
Therapeutic intervention
The negative physical, psychological, cognitive and epigenetic effects of foster care have been established in
innumerable studies in various countries. The Casey Family Programs Northwest Foster Care Alumni Study was a
fairly extensive study into various aspects of the psychosocial effects of foster care noted that 80% of ex-foster
children are doing "poorly".
Neuroplasticity
The human brain however has been shown to have a fair degree of neuroplasticity.[113] [114] [115] Adult neurogenesis
has been shown to be an ongoing process.[116]
"... all those experiences are of much significance which show how the judgment of the senses may be modified by
experience and by training derived under various circumstances, and may be adapted to the new conditions..." Hermann von Helmholtz, 1866
While having a background in foster homesespecially in instances of sexual abusecan be the precipitating factor
in a wide variety of psychological and cognitive deficits such as ADHD,[117] and PTSD,[52] [118] it may also serve to
obfuscate the true cause of underlying issues. The foster care experience may have nothing to do with the symptoms,
or on the other hand, the symptoms may be exacerbated by having a history of foster care and the attendant abuses.
Children in the child welfare system have often experienced significant and repeated traumas. Dyadic
Developmental Psychotherapy is one of the approaches that has been used to treat the resulting trauma and
attachment difficulties caused by chronic early maltreatment within a care-giving relationship.[119] [120] [121]
Foster Parent and Child Reunions

Foster parents play an important pivotal role in the lives of infants placed in their care during critical developmental
periods. When orphaned, fostered, or adopted children suffering from genealogical bewilderment are curious to learn
about their family background and medial history, searches to locate former foster parents have potential to be just as
captivating, technically challenging, and convoluted as searching for biological parents. A successful reunion with a
loving set of benevolent caregiving foster parents also has potential to create positive emotional responses, stimulate
happiness through an increased sense of connectedness and sense of indebtedness, and provide a uniquely treasured
experience for children who were fostered. [122]
Foster care In popular culture

Fictional characters
In the Fox television show, Bones, forensic anthropologist Dr. Temperance Brennan (played by Emily
Deschanel) grew up in foster care when her parents went missing.[123]
ABC's Secret Life of the American Teenager's Ricky (played by Dareen Kagasoff) is in foster care.[124]
On TNT's Leverage, Parker (played by Beth Riesgraf) and Hardison (played by Aldis Hodge) both grew up in
foster care. While Hardison had a good experience with his "nana", Parker had several bad experiences with
several bad foster families.[125] [126]
The main and title character in the book The Great Gilly Hopkins is a foster child who wishes to be reunited
with their mother.
Famous former foster children
Allison Anders, writer and director
Alonzo Mourning, NBA Defensive Player of the Year in 1999 & 2000 and seven-time NBA All-Star
58
Foster care
59
Babe Ruth, American Major League baseball player
Eddie Murphy, actor
Eriq La Salle, actor
Esai Morales, actor
Marilyn Monroe, actress, singer and model
Victoria Rowell, dancer[127]
Wayne Dyer, author, motivational speaker, spiritual leader
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attachments/ 600_The Corrupt Business Of Child Protective Services. pdf). .
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org/ ?p=532). The Indypendent. 2005-12-08. . Retrieved 2011-11-01.
[88] Zito, JM; Safer, DJ; Sai, D; Gardner, JF; Thomas, D; Coombes, P; Dubowski, M; Mendez-Lewis, M (2008). "Psychotropic medication
patterns among youth in foster care". Pediatrics 121 (1): e15763. doi:10.1542/peds.2007-0212. PMID18166534.
[89] Psychiatry (Edgmont). 2008 April; 5(4): 2526. PMCID: PMC2719553 Elisa F. Cascade and Amir H. Kalali, MD Generic Penetration of
the SSRI Market (http:/ / www. ncbi. nlm. nih. gov/ pmc/ articles/ PMC2719553/ )
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ImprovingFamilyFosterCare. htm). Casey.org. . Retrieved 2011-11-01.
[93] "South Bay sex-abuse lawsuit: Ex-foster child awarded $30 million - San Jose Mercury News" (http:/ / www. mercurynews. com/
ci_15684415?nclick_check=1). Mercurynews.com. . Retrieved 2011-11-01.
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20100805006437/ en/ Estey-Bomberger-announces-Jury-Awards-30-Million). .
[95] Aimee Green, The Oregonian. "Gresham foster kids abused despite DHS checks" (http:/ / www. oregonlive. com/ news/ index. ssf/ 2009/
04/ gresham_foster_kids_abused_des. html). OregonLive.com. . Retrieved 2011-11-01.
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[121] Hughes, D., Attachment Focused Family Therapy, Norton: NY, 2009
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[127] "Foster to Famous" (http:/ / www. fosterclub. com/ famous). Fosterclub.com. . Retrieved 2011-11-01.
Further reading
Hurley, Kendra (2002). "Almost Home" (http://www.nhi.org/online/issues/125/fostercare.html) Retrieved
June 27, 2006.
Carlson, E.A. (1998). "A prospective longitudinal study of disorganized/disoriented attachment". Child
Development 69 (4): 11071128. PMID9768489.
Knowlton, Paul E. (2001). "The Original Foster Care Survival Guide"; A first person account directed to
successfully aging out of foster care.
McCutcheon, James, 2010. "Historical Analysis and Contemporary Assessment of Foster Care in Texas:
Perceptions of Social Workers in a Private, Non-Profit Foster Care Agency". Applied Research Projects. Texas
State University Paper 332. (http://ecommons.txstate.edu/arp/332)
External links
The Mental Health of Children in Out-of-Home Care: Scale and Complexity of Mental Health Problems (http://
www.medscape.com/viewarticle/575410_2)
Effects of Enhanced Foster Care on the Long-term Physical and Mental Health of Foster Care Alumni (http://
archpsyc.ama-assn.org/cgi/content/full/65/6/625)
63
Orphan
64
Orphan
An orphan (from the Greek [1] ) is a child permanently
bereaved of or abandoned by his or her parents.[2] [3] In common usage,
only a child (or the young of an animal) who has lost both parents is
called an orphan. However, adults can also be referred to as orphans, or
"adult orphans".
In certain animal species where the father typically abandons the
mother and young at or prior to birth, the young will be called orphans
when the mother dies regardless of the condition of the father.
Definitions
Various groups use different definitions to identify orphans. One legal
definition used in the United States is a minor bereft through "death or
disappearance of, abandonment or desertion by, or separation or loss
from, both parents".[4]
Orphans by Thomas Kennington
In the common use, an orphan does not have any surviving parent to
care for him or her. However, the United Nations Children's Fund
(UNICEF), Joint United Nations Programme on HIV and AIDS (UNAIDS), and other groups label any child that has
lost one parent as an orphan. In this approach, a maternal orphan is a child whose mother has died, a paternal
orphan is a child whose father has died, and a double orphan has lost both parents.[5] This contrasts with the older
use of half-orphan to describe children that had lost only one parent.[6]
Populations
Orphans are relatively rare in developed countries, as most children can expect both of
their parents to survive their childhood. Much higher numbers of orphans exist in
war-torn nations such as Afghanistan. After years of war, there are an estimated 1.5
million orphans in Afghanistan.[7]
An Afghan girl in a Kabul

orphanage.
Orphan
65
Continent
Number of
orphans (1000s)
Orphans as
percentage
of all children
Africa
34,294
11.9%
Asia
65,504
6.5%
8,166
7.4%
107,964
7.6%
Latin America & Caribbean

Total
2001 figures from 2002 UNICEF/UNAIDS report[8]

China: A survey conducted by the Ministry of Civil Affairs in 2005 showed that China has about 573,000
orphans below 18 years old.[9]
Russia: An estimated 650,000 children are in Russian orphanages. Orphans are turned out of the orphanages at
the age of 16, and the results are poor for most of them: 40% are homeless, 20% turn to crime, and 10% commit
suicide.[10]
Notable orphans
Famous orphans include world leaders such as Nelson Mandela and Andrew Jackson; the Muslim prophet
Mohammed; writers such as Edgar Allan Poe, and Leo Tolstoy. The American orphan Henry Darger portrayed the
horrible conditions of his orphanage in his art work. Other notable orphans include entertainment greats such as
Louis Armstrong, Johann Sebastian Bach, Marilyn Monroe, Babe Ruth and Aaron North, and innumerable fictional
characters in literature and comics.
History
Wars and great epidemics,such as AIDS, have created many orphans. World War Two, with its massive numbers of
deaths and population movements created large numbers of orphanswith estimates for Europe ranging from
1,000,000 to 13,000,000. Judt (2006) estimates there were 9,000 orphaned children in Czechoslovakia, 60,000 in the
Netherlands 300,000 in Poland and 200,000 in Yugoslavia, plus many more in the Soviet Union, Germany, Italy and
elsewhere.[11]
Orphan
66
In literature
Orphaned characters are extremely common as literary protagonists,
especially in children's and fantasy literature.[12] The lack of parents
leaves the characters to pursue more interesting and adventurous lives,
by freeing them from familial obligations and controls, and depriving
them of more prosaic lives. It creates characters that are self-contained
and introspective and who strive for affection. Orphans can
metaphorically search for self-understanding through attempting to
know their roots. Parents can also be allies and sources of aid for
children, and removing the parents makes the character's difficulties
more severe. Parents, furthermore, can be irrelevant to the theme a
writer is trying to develop, and orphaning the character frees the writer
from the necessity to depict such an irrelevant relationship; if one
parent-child relationship is important, removing the other parent
prevents complicating the necessary relationship. All these
characteristics make orphans attractive characters for authors.
Orphans are common in fairy tales, such as most variants of
Cinderella.
Mime offers food to the young Siegfried, an

orphan he is raising; Illustration by Arthur
Rackham to Richard Wagner's Siegfried
A number of well-known authors have written books featuring orphans. Examples from classic literature include
Charlotte Bront, Charles Dickens, Mark Twain's Tom Sawyer, L. M. Montgomery's Anne of Green Gables books,
and J. R. R. Tolkien. Among more recent authors, A. J. Cronin, Lemony Snicket, Roald Dahl, J. K. Rowling's Harry
Potter series, as well as some less well-known authors of famous orphans like Little Orphan Annie have used
orphans as major characters. One recurring storyline has been the relationship that the orphan can have with an adult
from outside his or her immediate family as seen in Lyle Kessler's play Orphans.
In religious texts
Many religious texts, including the Bible and the Quran, contain the idea that helping and defending orphans is a
very important and God-pleasing matter. Several citations:
"Do not take advantage of a widow or an orphan." (Hebrew Bible, Exodus 22:22)
"Leave your orphans; I will protect their lives. Your widows too can trust in me." (Hebrew Bible, Jeremiah 49:11)
"Religion that God our Father accepts as pure and faultless is this: to look after orphans and widows in their
distress and to keep oneself from being polluted by the world." (The New Testament, James 1:27)
"And they feed, for the love of Allah, the indigent, the orphan, and the captive," - (The Quran, The Human: 8)
"Therefore, treat not the orphan with harshness," (The Quran, The Morning Hours: 9)
References
[1] (http:/ / www. perseus. tufts. edu/ hopper/ text?doc=Perseus:text:1999. 04. 0057:entry=o)rfano/ s), Henry George Liddell, Robert
Scott, A Greek-English Lexicon, on Perseus
[2] Merriam-Webster online dictionary (http:/ / www. merriam-webster. com/ dictionary/ orphan)
[3] Concise Oxford Dictionary, 6th edition "a child bereaved of parents" with bereaved meaning (of death etc) deprived of a relation
[4] Iii. Eligibility For Immigration Benefits As An Orphan (http:/ / www. uscis. gov/ portal/ site/ uscis/ menuitem.
5af9bb95919f35e66f614176543f6d1a/ ?vgnextoid=17f496981298d010VgnVCM10000048f3d6a1RCRD&
vgnextchannel=063807b03d92b010VgnVCM10000045f3d6a1RCRD)
[5] UNAIDS Global Report 2008 (http:/ / data. unaids. org/ pub/ GlobalReport/ 2008/ jc1510_2008_global_report_pp11_28_en. pdf)
[6] See, for example, this 19th century news story (http:/ / www. olivetreegenealogy. com/ orphans/ society-half-orphan-asylum. shtml) about
The Society for the Relief of Half-Orphan and Destitute Children, or this one (http:/ / query. nytimes. com/ gst/ abstract.
html?res=9B00E1D9163AE033A25755C1A9649D94669FD7CF) about the Protestant Half-Orphan Asylum.
Orphan
[7] Virginia Haussegger Mahboba's promise ABC TV 7.30 Report. 2009. http:/ / www. abc. net. au/ 7. 30/ content/ 2009/ s2615472. htm (last
accessed 15 July 2009)
[8] TvT Associates/The Synergy Project (July 2002). "Children on the Brink 2002: A Joint Report on Orphan Estimates and Program Strategies"
(http:/ / www. usaid. gov/ pop_health/ aids/ Publications/ docs/ childrenbrink. pdf). UNAIDS and UNICEF. .
[9] China to insure orphans as preventitive health measure (http:/ / news. xinhuanet. com/ english/ 2009-07/ 21/ content_11745889. htm)
[10] " A Summer of Hope for Russian Orphans (http:/ / www. nytimes. com/ 2002/ 07/ 21/ nyregion/ a-summer-of-hope-for-russian-orphans.
html?pagewanted=all)". The New York Times. July 21, 2002.
[11] For a high estimate see I.C.B. Dear and M.R.D. Foot, eds. The Oxford companion to World War II (1995) p 208; for lower Tony Judt,
Postwar: a history of Europe since 1945 (2006) p. 21
[12] Philip Martin, The Writer's Guide to Fantasy Literature: From Dragon's Lair to Hero's Quest, p 16, ISBN 0-87116-195-8
Bibliography
Bullen, John. "Orphans, Idiots, Lunatics, and Historians: Recent Approaches to the History of Child Welfare in
Canada," Histoire Sociale: Social History, May 1985, Vol. 18 Issue 35, pp 133145
Harrington, Joel F. "The Unwanted Child: The Fate of Foundlings, Orphans and Juvenile Criminals in Early
Modern Germany (2009)
Keating, Janie. A Child for Keeps: The History of Adoption in England, 1918-45 (2009)
Miller, Timothy S. The Orphans of Byzantium: Child Welfare in the Christian Empire (2009)
Safley, Thomas Max. Children of the Laboring Poor: Expectation and Experience Among the Orphans of Early
Modem Augsburg (2006)
Sen, Satadru. "The orphaned colony: Orphanage, child and authority in British India," Indian Economic and
Social History Review, Oct-Dec 2007, Vol. 44 Issue 4, pp 463-488
Terpstra, Nicholas. Abandoned Children of the Italian Renaissance: Orphan Care in Florence and Bologna
(2005)
United States
Berebitsky, Julie. Like Our Very Own: Adoption and the Changing Culture of Motherhood, 1851-1950 (2000)
Carp, E. Wayne, ed. Adoption in America: Historical Perspectives (2003)
Hacsi, Timothy A. A Second Home: Orphan Asylums and Poor Families in America (1997)
Herman, Ellen. "Kinship by Design: A History of Adoption in the Modern United States (2008) ISBN
9780226327600
Kleinberg, S. J. Widows And Orphans First: The Family Economy And Social Welfare Policy, 1880-1939 (2006)
Miller, Julie. Abandoned: Foundlings in Nineteenth-Century New York City (2007)
67
AIDS orphan
68
AIDS orphan
An AIDS orphan is a child who became an orphan because one or
both parents died from AIDS.
In statistics from the Joint United Nations Programme on HIV/AIDS
(UNAIDS), the World Health Organization (WHO) and the United
Nations Children's Fund (UNICEF), the term is used for a child whose
mother has died due to AIDS before the child's 15th birthday,
regardless of whether the father is still alive.[1] As a result of this
definition, one study estimated that 80% of all AIDS orphans still have
one living parent.[2]
There are 70,000 new AIDS orphans a year.[3] By the year 2010, it is
estimated that over 20 million children will be orphaned by AIDS.[4]
Because AIDS affects mainly those who are sexually active,
AIDS-related deaths are often people who are their family's primary
wage earners. The resulting AIDS orphans frequently depend on the
state for care and financial support, particularly in Africa.[5]
Aids orphans in Malawi
The highest number of orphans due to AIDS alive in 2007 was in

South Africa[5] (although the definition of AIDS orphan in South African statistics includes children up to the age of
18 who have lost either biological parent).[6] In 2005 the highest number of AIDS orphans as a percentage of all
orphans was in Zimbabwe.[5]
References
[1] UNAIDS.org (http:/ / data. unaids. org/ Publications/ IRC-pub05/ orphrept_en. pdf) PDF
[2] Stuijt, Adriana (04 April 2009). "South Africa's 3,4-million Aids-orphans to get 'adult' rights" (http:/ / www. digitaljournal. com/ article/
270409). .
[3] AIDS Orphan's Preventable Death Challenges Those Left Behind (http:/ / www. time. com/ time/ world/ article/ 0,8599,128736,00. html), by
Tony Karon, June 01, 2001
[4] Project Aids Orphan (http:/ / www. projectaidsorphan. org/ about. php)
[5] "AIDS orphans" (http:/ / www. avert. org/ aidsorphans. htm). Avert. . Retrieved 2006-10-08.
[6] children count (http:/ / www. childrencount. ci. org. za/ content. asp?TopLinkID=6& PageID=18) Government of South Africa
External links
AIDS Orphan Resources Around the Globe (http://www.thebody.com/content/art1111.html)
!Nam Child Wiki (http://www.namchild.gov.na) (Namibian Wiki on Children)
Orphanage
69
Orphanage
An orphanage is a residential institution devoted to the care of
orphans children whose parents are deceased or otherwise unable or
unwilling to care for them. Parents, and sometimes grandparents, are
legally responsible for supporting children, but in the absence of these
or other relatives willing to care for the children, they become a ward
of the state, and orphanages are one way of providing for their care and
housing. However some orphanages, especially in developing countries
will prey on vulnerable families at risk of breakdown and actively
recruit children, orphanages in developing countries are rarely run by
the state[1] [2]
Former Berlin Pankow orphanage
In some places, orphanages are slowly being phased out in many

countries in favour of direct support to vulnerable children, foster care
or adoption. Few large international charities continue to fund them,
however they are still commonly founded by smaller charities and
religious groups.[1]
Other residential institutions for children can be called group home,
children's home, rehabilitation center or youth treatment center.
Comparison to alternatives
St. Nicholas Orphanage in Novosibirsk, Russia
During the 20th century, conventional wisdom held that orphanages,

especially large orphanages, were the worst possible care option for children.[3] [4] In large institutions, babies may
not receive enough eye contact, physical contact, and stimulation to promote proper physical, social or cognitive
development.[5] [6] In the worst cases, orphanages can be dangerous and unregulated places where children are
subject to abuse and neglect.[7] [8] [9]
However, researchers from Duke University have shown that institutional care in America in the 20th century
produced the same health, emotional, intellectual, mental, and physical outcomes as care by relatives, and better than
care in the homes of strangers.[10] One explanation for this is the prevalence of permanent temporary foster care.
This is the name for a long string of short stays with different foster care families.[10] Permanent temporary foster
care is highly disruptive to the child and prevents the child from developing a sense of security or belonging.
Compared to foster care, orphanages are generally more expensive.[10]
Whereas orphanages are intended to be reasonably permanent placements, group homes may be used for short-term
placements. They may be residential treatment centers, and they frequently specialize in a particular population with
psychiatric or behavioral problems, e.g., a group home for children and teens with autism, eating disorders, or
substance abuse problems or child soldiers undergoing decommissioning.
Placement in the home of a relative maintains and usually improves the child's connection to family members. In the
some cases, the biological family can also be dangerous to a child.[10] [11]
Orphanage
Deinstitutionalisation
Increasingly there is a move to Deinstitutionalise child care systems. This involves closing down orphanages and
other institutions for children and developing replacement services. The first option for a child is to see if they can be
reunited with their biological or extended family. Often circumstances will have changed since the separation. If that
is not possible domestic adoption or long term fostering are considered. Older children may be supported to
independence. Disabled children may need small family type homes where their needs can be catered for.
It is important to understand the reasons for child abandonment then set up targeted alternative services to support
vulnerable families at risk of separation[12] such as mother and baby units and day care centres.[13]
History
The first orphanages, called "orphanotrophia", were founded in the 1st century amid various alternative means of
orphan support. Jewish law, for instance, prescribed care for the widow and the orphan, and Athenian law supported
all orphans of those killed in military service until the age of eighteen. Plato (Laws, 927) says: "Orphans should be
placed under the care of public guardians. Men should have a fear of the loneliness of orphans and of the souls of
their departed parents. A man should love the unfortunate orphan of whom he is guardian as if he were his own
child. He should be as careful and as diligent in the management of the orphan's property as of his own or even more
careful still."[14] The care of orphans was referred to bishops and, during the Middle Ages, to monasteries. Many
orphanages practiced some form of "binding-out" in which children, as soon as they were old enough, were given as
apprentices to households. This would ensure their support and their learning an occupation.
Such practices are assumed to be quite rare in the modern Western world, thanks to improved social security such as
the Social Security Act which allowed Aid to Dependent Children (ADC) to be passed. This marked a change in
social attitudes. This lack of social security and failure to develop alternative ways to support vulnerable families is
the key reason that orphanages remain in many other countries.
The deinstitutionalisation programme sped up in the 1950s, after a series of scandals involving the coercion of birth
parents and abuse of orphans (notably at Georgia Tann's Tennessee Children's Home Society), the United States and
other countries have moved to de-institutionalize the care of vulnerable childrenthat is, close down orphanages in
favor of foster care and accelerated adoption. Moreover, as it is no longer common for birth parents in Western
countries to give up their children, and as far fewer people die of diseases or violence while their children are still
young, the need to operate large orphanages has decreased.
Major charities are increasingly focusing their efforts on the re-integration of orphans in order to keep them with
their parents or extended family and communities. Orphanages are no longer common in the European community,
and Romania in particular has struggled to reduce the visibility of its children's institutions to meet conditions of its
entry into the European Union. In the United States, the largest remaining orphanage is the Bethesda Orphanage,
founded in 1740 by George Whitefield.
In many works of fiction (notably Oliver Twist and Annie), the administrators of orphanages are depicted as cruel
monsters. It is true that some orphanages are funded on a per child basis and there can be attempts made to
encourage children from poor families to enter the orphanage which will provide food, clothing and an education but
often lack the individual love required for full cognitive development.
Orphanage Scams
Visitors to developing countries can be taken in by orphanage scams, these can include orphanages created for the
day[15] or orphanages as a front to get foreigners to pay school fees of orphanage director's extended families.[16]
Alternatively the children whose upkeep is being funded by foreigners may be sent to work, not to school, the exact
opposite of what the donor is expecting.[17] The worst even sell children.[18] [19] [20] In Cambodia some are bought
from their parents for very little and passed on to westerners who pay a large fee so they can adopt them.[21] . This
70
Orphanage
71
also happens in China[22] . In Nepal orphanages can be used as a way to remove a child from their parents before
placing them for adoption overseas which is equally lucrative to the owners who will receive a number or official
and unofficial payments and 'donations'[23] [24] .
Europe
The orphanages and institutions remaining in Europe tend to be state funded.
Albania
There are approximately 10 small orphanages in Albania; each one having only 12-40 children residing there.[25]
Bosnia and Herzegovina

SOS Children's Villages giving support to 240 orphaned children.[26]
Bulgaria
The Bulgarian government has giving interest to strength the children's rights.
In November 2007, Bulgaria adopted a national strategic plan for the period 20082018 to improve the living
standards of the country's children. Bulgaria is working hard to get all institutions closed within the next few years
and find alternative ways to take care of the children.
Support is given to poor families and work during daytime; correspondingly, day centers have started up. A smaller
number of children have also been able to be relocated into foster families".[27] [28]
There are living 7000[29] children in Bulgarian orphanages wrongly classified as orphaned. Only 10% of them are
orphans, with the rest of the children placed in orphanages in temporary periods when the family is in crisis.[30]
United Kingdom
During the Victorian Era, child abandonment was rampant, and orphanages were set up to reduce infant mortality.
Such places were often so full of children that "killing nurses" often administered Godfrey's Cordial, a special
concoction of opium and treacle, to soothe colic in babies.[31]
Many orphaned children were placed in either prisons or the workhouse, as there were so few places in orphanages,
or else they were left to fend for themselves on the street. Such places as were available could only be obtained by
procuring votes for admission, placing them out of reach of poor families.
Known orphanages are:
Founded
in
Name
Location
Founder
1795
Bristol Asylum for Poor Orphan Girls (Blue Maids'

Orphanage)
nr Stokes Croft turnpike, Bristol
1800
St Elizabeth's Orphanage of Mercy
Eastcombe, Glos
1813
London Asylum for Orphans
Hackney, London
Rev Andrew Reed
1822
Female Orphan Asylum
Brighton
Francois de Rosaz
1827
Infant Orphan Asylum
Wanstead
Rev Andrew Reed
1829
Sailor Orphan Girls School
London
1836
Ashley Down orphanage
Bristol
George Mller
1844
Asylum for Fatherless Children
Purley
Rev Andrew Reed
1854
Wolverhampton Orphan Asylum
Goldthorn Hill, Wolverhampton
John Lees
Orphanage
72
1856
Wiltshire Reformatory
Warminster
1860
Major Street Ragged Schools
Liverpool
Canon Thomas Major Lester
1861
St. Philip Neri's orphanage for boys
Birmingham
Oratorians
1861
Adult Orphan Institution
St Andrew's Place, Regent's Park, London
1861
British Orphan Asylum
Clapham, London
1861
Female Orphan Asylum
Westminster Road, London
1861
Female Orphan Home
Charlotte Row, St Peter Walworth,

London
1861
Jews' Orphan Asylum
Goodmans Fields, Whitechapel, London
1861
London Orphan Asylum
Hackney, London
1861
Merchant Seamen's Orphan Asylum
Bromley St Leonard, Bow, London
1861
Orphan Working School
Haverstock Hill, Kentish Town, London
1861
Orphanage
Eagle House, Hammersmith, London
1861
The Orphanage Asylum
Christchurch, Marylebone, London
1861
The Sailors' Orphan Girls' School & Home
Hampstead, London
1862
Swansea Orphan Home for Girls
Swansea
1865
The Boys' Home Regent's Park
London
1866
Dr Barnado's
various
1866
National Industrial Home for Crippled Boys
London
1867
Peckham Home for Little Girls
London
1868
The Boys' Refuge
Bisley
1868
Royal Albert Orphanage
Worcester
1868
Worcester Orphan Asylum
Worcester
1869
Ely Deaconesses Orphanage
Bedford
Rev TB Stevenson
1869
Orphanage and Almshouses
Erdington
Josiah Mason
1869
The Neglected Children of Exeter
Exeter
1869
Alexandra Orphanage for Infants
Hornsey Rise, London
1869
Stockwell Orphanage
London
1869
New Orphan Asylum
Upper Henwick, Worcs
1869
Wesleyan Methodist National Children's Homes
various
1869
London Orphan Asylum
Watford
1870
Fegans Homes
London
1870
Manchester and Salford Boys' and Girls' Refuge
Manchester
1871
Wigmore
West Bromwich and Walsall
WJ Gilpin
1872
Middlemore Home
Edgbaston
Dr John T. Middlemore
1872
St Theresa Roman Catholic Orphanage for Girls
Plymouth
1873
Dr Thomas Barnado
Maria Rye
Charles Spurgeon
Rev Thomas Bowman

Stephenson
James William Condell Fegan
Ryelands Road Leominster
1874
Cottage Homes for Children
West Derby
Mrs Nassau Senior
1875
Aberlour Orphanage
Aberlour, Scotland
Rev Charles Jupp
Orphanage
73
1877
All Saints Boys' Orphanage
Lewisham, London
1880
Birmingham Working Boy's Home (for boys over the

age of 13)
Birmingham
Major Alfred V. Fordyce
1881
The Waifs and Strays' Society
East Dulwich, London
Edward de Montjoie Rudolf
1881
Catholic Childrens Protection Society
Liverpool
1881
Dorset County Boys Home
Milborne St Andrew
1881
Brixton Orphanage
Brixton Road, Lambeth, London
1881
Jews Hospital & Orphan Asylum
Knights Hill Road, Norwood, London
1881
Orphanage Infirmary
West Square, London Road, Southwark,

London
1881
Orphans' Home
South Street. London Road, Southwark,

London
1882
St Michael's Home for Friendless Girls
Salisbury
1890
St Saviour's Home
Shrewsbury
1890
Orphanage of Pity
Warminster
1890
Wolverhampton Union Cottage homes
Wolverhampton
1892
Calthorpe Home For Girls
Handsworth, Birmingham
1918
Painswick Orphanage
Painswick
unknown
Clio Boys' Home
Liverpool
unknown
St Philip's Orphanage, (RC Institution for Poor Orphan

Children)
Brompton, Kensington
Estonia
As of 2009, there are 35 orphanages, which houses approximately 1300 orphaned children.[32] [33]
Hungary
A comprehensive national strategy for strengthening the rights of children adopted by Parliament in 2007 and will
run until 2032.
Child flow to orphanages has been stopped and they are now protected by social services. Violation of children's
rights leads to court.[34]
Lithuania
In Lithuania there are 105 institutions. 41 percent of the institutions have each more than 60 children. Lithuania has
the highest number of orphaned children in Northern-Europe.[35] [36]
Poland
Children's rights enjoys a relatively strong protection in Poland. Orphaned children are now protected by social
services.
Social Workers' opportunities have increased by get more foster homes established and aggressive family members
can now be forced away from home, instead of re-placing the child / children.[37]
Orphanage
74
Republic of Moldova
More than 8800 children expected to grow up at any kind of state institution, but only 3 percent of them are
orphans.[38]
Romania
The Romanian child welfare system is in the process of revising itself and has reduced the flow of infants into
orphanages.[39]
According to Baroness Emma Nicholson, in some counties Romania now has "a completely new, world class, state
of the art, child health development policy." But several Dickensian orphanages remain in Romania.[40]
Romania still has the highest number of orphaned children in Europe, but by 2020 Romanian institutions should be a
thing of the past with family care services will replacing the old system. All children in need will be protected by
social services by 2020.[41]
As of 2011, there are 10,833 orphaned children in 256 large institutions in Romania.[42]
#
year
Total children in care of the state.
Number of children in orphanages
1.
1990
47,405
2.
1994
52,986
3.
1997
51468
39,569
4.
1998
55641
38,597
5.
1999
57087
33,356
6.
2000
83907
53,335
7.
2001
78000
47,171
8.
2002
87867
49,965
9.
2003
86379
43,092
10. 2004
84445
37,660
11. 2005
83059
32,821
12. 2006
78766
28,786
13. 2007
73793
26,599
14. 2008
71047
24,979
15. 2009
68858
24,227
16. 2010
62000
19,000
17. 2011
50000
10,833
[43]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
[51]
[52] [53]
[54]
[55] [56]
The reason of the large change of children protected by the state in 2000 comparing with 1999 is that many
children's hospital and residential schools for small children where redesigned in to orphanages in year 2000.
Orphanage
Serbia
There are many state orphanages "where several thousand children are kept and which are still part of an outdated
child care system". The conditions for them are bad because the government doesn't paid rapidly attention to
improve the living standards for disabled children in Serbia's orphanages and medical institutions.[57]
Slovakia
The Committee gave some recommendations, such as proposals for the adoption of a new "national 14" action plan
for children for at least the next five years, and the creation of an independent institution for the protection of child
rights.[58]
Sweden
In Sweden there are 5,000 children in the care of the state. None of them are currently living in an orphanage,
because there is a social service law which requires that the children reside in a family home.
Sub Saharan Africa

Whilst some African orphanages are state funded the majority (especially in Sub Saharan Africa) appear to be
funded by donors, often from Western nations.
Ethiopia
"For example, in the Jerusalem Association Children's Home (JACH), only 160 children remain of the 785 who were
in JACH's three orphanages." / "Attitudes regarding the institutional care of children have shifted dramatically in
recent years in Ethiopia. There appears to be general recognition by MOLSA and the NGOs with which Pact is
working that such care is, at best, a last resort, and that serious problems arise with the social reintegration of
children who grow up in institutions, and deinstitutionalization through family reunification and independent living
are being emphasized."[59]
Ghana
A 2007 survey sponsored by OrphanAid Africa and carried out by the Department of Social Welfare came up with
the figure of 4,800 children in institutional care in 148 orphanages.Of these at least four have since been closed. The
website www.ovcghana.org details these reforms.
Kenya
A 1999 survey of 35,000 orphans found the following number in institutional care: 64 in registered institutions and
164 in unregistered institutions.[60]
Rwanda
Out of 400,000 orphans, 5,000 are living in orphanages.[61] The Government of Rwanda are working with Hope and
Homes for Children to close the first institution and develop a model for community based childcare which can be
used across the country and ultimately Africa[62]
Tanzania
"Currently, there are 52 orphanages in Tanzania caring for about 3,000 orphans and vulnerable children."[63] A world
bank document on Tanzania showed it was six times more expensive to institutionalise a child there than to help the
family become functional and support the child themselves.
75
Orphanage
Nigeria
In Nigeria, a rapid assessment of orphans and vulnerable children conducted in 2004 with UNICEF support revealed
that there were about seven millions orphans in 2003 and that 800,000 more orphans were added during that same
year. Out of this total number, about 1.8million are orphaned by HIV/AIDS. With the spread of HIV/AIDS, the
number of orphans is expected to increase rapidly in the coming years to 8.2million by 2010.[64]
South Africa
Since 2000, South Africa does not licence orphanages any more but they continue to be set up unregulated and
potentially more harmful. Theoretically the policy supports community based family homes but this is not always the
case. One example is the homes operated by Thokomala, http://www.thokomala.org.za.
Zambia
A 1996 national survey of orphans revealed no evidence of orphanage care. The breakdown of care was as follows:
38% grandparents 55% extended family 1% older orphan 6% non-relative Recently a group of students started a
fundraising website for an orphanage in Zambia. http://mmorphanage.org[60]
Zimbabwe
There are 38 privately run children's charity homes, or orphanages, in the country, and the government operates eight
of its own.
Statistics on the total number of children in orphanages nationwide are unavailable, but caregivers say their facilities
were becoming unmanageably overwhelmed almost on a daily basis. Between 1994 and 1998, the number of
orphans in Zimbabwe more than doubled from 200,000 to 543,000, and in five years, the number is expected to
reach 900,000. (Unfortunately, there is no room for these children.)[65]
Togo
In Togo, there were an estimated 280,000 orphans under 18 years of age in 2005, 88,000 of them orphaned by
AIDS.[66] [66] Ninety-six thousand orphans in Togo attend school.[66]
Sierra Leone[67]
Children (017 years) orphaned by AIDS, 2005, estimate 31,000[68]
Children (017 years) orphaned due to all causes, 2005, estimate 340,000[68]
Orphan school attendance ratio, 19992005 71,000[68]
Senegal
Children (017 years) orphaned by AIDS, 2005, estimate 25,000[69]
Children (017 years) orphaned due to all causes, 2005, estimate 560,000[69]
Orphan school attendance ratio, 19992005 74,000[69]
SAARC Countries
Nepal
There are at least 602 child care homes housing 15,095 children in Nepal[70] "Orphanages have turned into a
Nepalese industry there is rampant abuse and a great need for intervention."[71] [72] Many do not require adequate
checks of their volunteers leaving children open to abuse.[73]
76
Orphanage
77
Afghanistan
"At Kabul's two main orphanages, Alauddin and Tahia Maskan, the number of children enrolled has increased
almost 80 percent since last January, from 700 to over 1,200 children. Almost half of these come from families who
have at least one parent, but who can't support their children."[74] The non-governmental organisation Mahboba's
promise assists orphans in contemporary Afghanistan.[75]
Bangladesh
"There are no statistics regarding the actual number of children in welfare institutions in Bangladesh. The
Department of Social Services, under the Ministry of Social Welfare, has a major programme named Child Welfare
and Child Development in order to provide access to food, shelter, basic education, health services and other basic
opportunities for hapless children." (The following numbers mention capacity only, not actual numbers of orphans at
present.)
9,500 -State institutions
250 -babies in three available "baby homes"
400 -Destitute Children's Rehabilitation Centre
100 -Vocational Training Centre for Orphans and Destitute Children
1,400 -Sixty-five Welfare and Rehabilitation Programmes for Children with Disability
The private welfare institutions are mostly known as orphanages and madrassahs. The authorities of most of these
orphanages put more emphasis on religion and religious studies. One example follows: 400 Approximately
Nawab Sir Salimullah Muslim Orphanage[76]
Maldives
Orphans, Children (017 years) orphaned due to all causes, 2010, estimate 51 "Minivan News"
April 2007.
[77]
. Retrieved 6
The Far East

Taiwan
The number of orphanages and orphans drastically dropped from 15 institutions and 2,216 persons in 1971 to 9
institutions and 638 persons by the end of 2001.
South Korea
"There are now 17,000 children in public orphanages throughout the country and untold numbers at private
institutions."[78]
Cambodia
There are numerous NGOs focusing their efforts on assisting Cambodia's orphans: one group, "World Orphans"
constructed 47 orphanages housing over 1500 children in a three year period.[79] The total number of orphans is
much higher, but unknown: "There are no accurate figures available on how many orphans there are in Cambodia."
One charity named C.H.O.I.C.E. is run by expats based in the capital city of Phnom Penh; it helps support orphans
and other poor and homeless people.
Orphanage
China
"Currently there are 50,000 children in Chinese orphanages, while the number of abandoned children shows no sign
of slowing." "Official figures show that fewer than 20,000 of China's orphans are now in any form of institutional
care." Chinese official records fail to account for most of the country's abandoned infants and children, only a small
proportion of whom are in any form of acknowledged state care. The most recent figure provided by the government
for the country's orphan population, 100,000, seems implausibly low for a country with a total population of
1.2billion. Even if it were accurate, however, the whereabouts of the great majority of China's orphans would still be
a complete mystery, leaving crucial questions about the country's child welfare system unanswered and suggesting
that the real scope of the catastrophe that has befallen China's unwanted children may be far larger than the evidence
in this report documents.
Laos
"It is stated that there are 20,000 orphaned children in Laos. There are only three orphanages in the whole country
providing places for a total of 1,000 of these children." No Title. By Anneli Dahlbom One of the largest orphanages
in Laos is in the town of Phonsavan. It is an S.O.S. orphanage and there are over 120 orphans living in the
facility.[80]
The Middle East and North Africa

Egypt
"The [Mosques of Charity] orphanage houses about 120 children in Giza, Menoufiya and Qalyubiya." "We [Dar
Al-Iwaa] provide free education and accommodation for over 200 girls and boys." "Dar Al-Mu'assassa Al-Iwaa'iya
(Shelter Association), a government association affiliated with the Ministry of Social Affairs, was established in
1992. It houses about 44 children." There are also 192 children at The Awlady, 30 at Sayeda Zeinab orphanage, and
300 at My Children Orphanage.
Note: There are about 185 orphanages in Egypt. The above information was taken from the following articles:
"Other families" by Amany Abdel-Moneim. Al-Ahram Weekly (5/1999). "Ramadan brings charity to Egypt's
orphans". Shanghai Star (12/13/2001). "A Child by Any Other Name" by Rhab El-Bakry. Egypt Today (11/2001).
Orphanage Project in Egyptwww.littlestlamb.org
Sudan
There is still at least one orphanage in Sudan although efforts have been made to close it[81]
Bahrain
The "Royal Charity Organization" [82] is a Bahraini governmental charity organization founded in 2001 by King
Hamad ibn Isa Al Khalifah to sponsor all helpless Bahraini orphans and widows. Since then almost 7,000 Bahraini
families are granted monthly payments, annual school bags, and a number of university scholarships. Graduation
ceremonies, various social and educational activities, and occasional contests are held each year by the organization
for the benefit of orphans and widows sponsored by the organization.
78
Orphanage
Iraq
UNICEF maintains the same number at present. "While the number of state homes for orphans in the whole of Iraq
was 25 in 1990 (serving 1,190 children); both the number of homes and the number of beneficiaries has declined.
The quality of services has also declined." A 1999 study by UNICEF "recommended the rebuilding of national
capacity for the rehabilitation of orphans." The new project "will benefit all the 1,190 children placed in
orphanages."
Palestinian Territory
"In 1999, the number of children living in orphanages witnessed a considerable drop as compared to 1998. The
number dropped from 1,980 to 1,714 orphans. This is due to the policy of child re-integration in their household
adopted by the Ministry of Social Affairs."
Former Soviet Union

In the post-Soviet countries, orphanages are
better known as the Children Homes
(Russian: e a). After reaching
school age, all children enroll into
internat-schools
(Russian:
-) (see Boarding school).
Russia
Over 700,000 orphans live in Russia,
increasing at the rate of 113,000 per year.
UNICEF estimates that 95% of these
children are social orphans, meaning that
The Moscow Orphanage (founded in 1763, constructed in the 1770s)
they have at least one living parent who has
given them up to the state. [83][84] [85] [86]
There are many web pages for Russian orphanages, but very few of them are in English, such as St Nicholas
Orphanage [87] in Siberia or the Alapaevsk orphanage in the Urals. "Of a total of more than 600,000 children
classified as being 'without parental care' (most of them live with other relatives and fosters), as many as one-third
reside in institutions."[88]
Azerbaijan
"Many children are abandoned due to extreme poverty and harsh living conditions. Family members or neighbors
may raise some of these children but the majority live in crowded orphanages until the age of fifteen when they are
sent into the community to make a living for themselves."[89]
Belarus
Approximate total 1,773 (1993 statistics for "all types of orphanages")
Kyrgyzstan
Partial information: 85 Ivanovka Orphanage[90]
79
Orphanage
Tajikistan
"No one can be sure how many lone children are there in the republic. About 9,000 are in internats and in
orphanages."[91]
Ukraine
103,000[92]
Other information:
thousands Zaporozhzhya region[93]

150 Kiev State Baby Orphanage[94]
30 Beregena Orphanage
120 Dom Invalid Orphanage[95]
Uzbekistan
Partial Information: 80 Takhtakupar Orphanage
Oceania
Indonesia
No verifiable information for the number of children actually in orphanages. The number of orphaned and
abandoned children is approximately 91,000. "Convention on the Rights of the Child" [96] (PDF). Archived from the
original [97] on 2007-11-29. Retrieved 2007-11-12.
Fiji
Orphans, children (017 years) orphaned due to all causes, 2005, estimate 25,000 "Unicef Fiji Statistics" [98].
North America & Caribbean

Haiti
Haitians and expatriate childcare professionals are careful to make it clear that Haitian orphanages and children's
homes are not orphanages in the North American sense, but instead shelters for vulnerable children, often housing
children whose parent(s) are poor as well as those who are abandoned, neglected or abused by family guardians.
Neither the number of children or the number of institutions is officially known, but Chambre de L'Enfance
Necessiteusse Ha_tienne (CENH) indicated that it has received requests for assistance from nearly 200 orphanages
from around the country for more than 200,000 children. Although not all are orphans, many are vulnerable or
originate in vulnerable families that "hoped to increase their children's opportunities by sending them to
orphanages." Catholic Relief Services provides assistance to 120 orphanages with 9,000 children in the West, South,
Southeast and Grand Anse, but these include only orphanages that meet their criteria. They estimate receiving ten
requests per week for assistance from additional orphanages and children's homes, but some of these are repeat
requests."[99]
In 2007, UNICEF estimated there were 380,000 orphans in Haiti, which has a population of just over 9 million,
according to the CIA World Factbook. However, since the January 2010 earthquake, the number of orphans has
skyrocketed, and the living conditions for orphans have seriously deteriorated. Official numbers are hard to find due
to the general state of chaos in the country.[100]
80
Orphanage
81
Mexico
"...at least 10,000 Mexican children live in orphanages and more live in unregistered charity homes"
Mexican Orphanages [101]
Mazatlan Mexico Orphanage [102]
Casa Hogar Jeruel: Orphanage in Chihuahua City, Mexico [103]
United States
The size of orphanages has declined over time, with many organizations preferring smaller "group home" sizes. Most
organizations provide a range of services to families in crisis, including mental health care, foster care, and
institutional placements.
Orphanages were relatively common until the end of the 20th century, and multiple retrospective studies indicate that
the former residents have higher than average educational outcomes and generally positive memories.[10] Only 3% of
former residents feel hostile towards the orphanages they were placed in.[10]
In the State of New York, slightly more than half of children in need of care are placed in foster care with strangers.
About one quarter are placed with relatives. Approximately one sixth are placed in orphanages, group homes, or
other types of institutional care.[104]
Partial information:
Bethesda Home for Boys, in Savannah, Georgia, is the oldest child caring institution in the country. In fact,
founded in 1740, it is older than the country itself and was a site frequently visited by many of the countrys
founding fathers. Benjamin Franklin was an early investor and Bethesda was constituted by a grant from King
George with the encouragement of Charles and John Wesley.
Established in 1790, the Charleston Orphan House, now called the Carolina Youth Development Center, located
in Charleston, SC, was the first public orphanage in the United States.[105]
Happy Hills Farm in Texas[10]
The Crossnore School, in the mountains of Crossnore, North Carolina[10]
Central and South America

Guatemala
"...currently there are about 20,000 children in orphanages."[106]
Peru
Casa Hoger Lamedas Pampa, in Huanaco
Significant charities that help orphans

Prior to the establishment of state care for orphans in First World
countries, many private charities existed to take care of destitute
orphans, over time other charities have found other ways to care
for children.
In a Colombian orphanage, a nurse takes care of three

children.
Hope and Homes for Children are working with Governments in many countries to deinstitutionalise their child
care systems.
SOS Children's Villages is the world's largest non-governmental, non-denominational child welfare organization
that still believes in building orphanages for children.
Orphanage
Dr Barnardo's Homes (now simply Barnardo's)
The Miracle Foundation is concerned with helping orphans in India.
ACTUP! is a student run charity set up in aid of an orphanage in the Vinh province, Vietnam. The group raises
money through theatrical performances and movie screenings.
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[39] http:/ / news. bbc. co. uk/ 2/ hi/ europe/ 6267121. stm Viewpoints: Balkan boost for EU
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[42] http:/ / www. hopeandhomes. org/ downloads/ HHC-ARK_brochure. pdf
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0,8599,1683763,00. html). Time. .
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[62] "Ministry of Gender and Family Promotion MINISTERS VISIT TO HOPE AND HOMES FOR CHILDREN (HHC)" (http:/ / www.
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83
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[103] http:/ / www. casahogarjeruel. org/
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[105] A Legacy of Caring: The Charleston Orphan House 17901990. Wyrick and Company, Charleston, SC 1991.
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External links
Keeping Children Out of Harmful Institutions: Why we should be investing in family-based care (http://www.
savethechildren.org.uk/en/54_9678.htm)
Closing Orphanages There is another way to care for the most vulnerable children (http://www.
hopeandhomes.org)
Rescued Orphans World's Largest Directory Of Orphanages (http://www.RescuedOrphans.org)
MyOrphanage.org In Touch With Orphanages (http://www.myorphanage.org)
Orphanage Review Board (http://www.parentless.org)
"Orphans and Orphanages". Catholic Encyclopedia. New York: Robert Appleton Company. 1913.
World orphanages website (http://www.orphanage.org/)
Aid to Vietnamese orphans (http://www.covsa.org/)
History of Beaver County Children's Home (http://bcch15066.org/)
Remembering Children Homes and Orphanages (http://childrenhomes.org/)
84
Third culture kid
85
Third culture kid

Third culture kid (TCK, 3CK) is a term coined in the early 1950s by American sociologist and anthropologist Ruth
Hill Useem "to refer to the children who accompany their parents into another society".[1] Other terms, such as
trans-culture kid, are also used by some. More recently, American sociologist David C. Pollock developed the
following description for third culture kids[2] :
A Third Culture Kid (TCK) is a person who has spent a significant part of [their] developmental years outside the parents' culture. The TCK
frequently builds relationships to all of the cultures, while not having full ownership in any. Although elements from each culture may be
assimilated into the TCK's life experience, the sense of belonging is in relationship to others of similar background.
General characteristics
TCKs tend to have more in common with one another, regardless of nationality, than they do with non-TCKs from
their passport country.[3] [4] TCKs are often multilingual and highly accepting of other cultures. Although moving
between countries may become an easy thing for some TCKs, after a childhood spent in other cultures, adjusting to
their passport country often takes years.
Before World War II, 66% of TCKs came from missionary families, and 16% came from business families. After
World War II, with the increase of international business and the rise of two international superpowers, the
composition of international families changed. Sponsors are generally broken down into five categories: missionary
(17%), business (16%), government (23%), military (30%), and "other" (14%).[5] Some TCK families migrate for
work independently of any organization based in their country of origin.
Origins and terminology

Dr. Useem coined the term third culture kid after her second year-long visit to India with her fellow
sociologist/anthropologist husband and three children.[6] In 1993 she wrote:
In summarizing that which we had observed in our cross-cultural encounters, we began to use the term "third
culture" as a generic term to cover the styles of life created, shared, and learned by persons who are in the
process of relating their societies, or sections thereof, to each other. The term "Third Culture Kids" or TCKs
was coined to refer to the children who accompany their parents into another society.
Ruth Hill Useem,TCK World: The Official Home of Third Culture Kids [7]
She describes the third culture as a shared, or interstitial way of life lived by those who had gone from one culture
(the home or first culture) to a host culture (the second) and had developed their own shared way of life with others
also living outside their passport cultures. Kay Eakin adapted this term and described a TCK as "someone who, as a
child, has spent a significant period of time in one or more culture(s) other than [their] own, thus integrating
elements of those cultures and their own birth culture, into a third culture".[3] Because culture by definition is
something that must be shared with others, David C. Pollock's definition recognizes the reality of what Eakin is
describing but takes it back to Useem's idea that, as with any culture, the "third culture" is a way of life shared with
others. Others have used different expressions to describe this same population. Currently they include 3CK or
trans-culture kid. Around 1985, Norma McCaig used the term Global Nomad essentially to define the same group
because (1) she didn't like being called a kid when she was grown up and (2) she wanted to make clear for future
research purposes that this experience happened because of a parent's career choice (which was the case with the
TCKs in Useem's first study, although Useem didn't mention this), not refugees or immigrants. McCaig did not want
the nuances particular to each type of experience to be lost. For this reason, Ruth Van Reken is now suggesting a
more comprehensive term, Cross-Cultural Kid (CCK), for all types of cross-cultural childhoods.
Third culture kid
Research
Research into third culture kids has come from two fronts. First, most of the research into TCKs has been conducted
by adult TCKs attempting to validate their own experiences. This research has been conducted largely at Michigan
State University, where Dr. Useem taught for over 30 years.[8] Second, the U.S armed forces has sponsored
significant research into the U.S. military brat experience.[8] Most TCK research on adults is limited to those people
whose time in a different culture occurred during the school age years.
Research into TCKs has either studied students currently living in a foreign culture or years later as adults. Since the
only way to identify somebody who grew up in a foreign culture is through self-identification, scientific sampling
methods on adults may contain bias due to the difficulty in conducting epidemiological studies across broad-based
population samples.
While much of the research into TCKs has shown consistent results across geographical boundaries, some
international sociologists are critical of the research that "expects there to be one unified 'true' culture that is shared
by all who have experiences of growing up overseas".[9]
Families
The parents of TCKs are often highly educated, successful in their careers, and are not likely to divorce.[10] When a
group (whether it is the military, a business, government, church, etc.) decides to send somebody to a foreign
country, it is making a significant investment. The group wants to send people who will represent it the best, and
provide the most value for the investment. TCKs will thus have a higher probability of coming from a family where
at least one parent earned a college degree and often an advanced degree. "Almost all" TCK families are deployed to
foreign countries as a result of the father's profession, and very few families live in another country primarily due to
the mother's occupation.[10]
TCKs also tend to come from families that are closer than non-TCK families. They will also have a smaller
likelihood of having divorced parents (divorced parents are unlikely to allow their former spouse to take their child
to another country). "Because the nuclear family is the only consistent social unit through all moves, family members
are psychologically thrown back on one another in a way that is not typical in geographically stable families."[11] It
has been observed that TCKs may be more prone to abuse as the family can become too tight knit. "The strength of
[the] family bond works to the benefit of children when parent-child communication is good and the overall family
dynamic is healthy. It can be devastating when it is not.... Physical, sexual and emotional abuse ... may go unnoticed
or unacknowledged by others for a variety of reasons, such as misguided notions about 'respecting privacy', or fear of
repatriation or family disgrace with colleagues".[11]
Sponsorship
TCK's exposure to foreign countries depends largely on parent's sponsoring organization. The sponsor affects many
variables such as: how long a family is in a foreign culture, the family's interaction with the host country nationals,
how enmeshed the family becomes with local practices, and the family's interaction with people from the home
country.
Military
Military brats are the most mobile of TCKs and spend an average of 7 (seven) years abroad while growing up. While
overseas a majority of non-infant and non-toddler military brats live off-base, due to budgeting priorities of military
bases, whereas bases tend to house more singles and families with very small children. Approximately 59% of
military brats spend more than 5 years in foreign countries. Because military bases aim for self-sufficiency, those
military brats who only live on base tend to be exposed the least to the local culture compared to other TCKs, but a
high percentage of military brats have lived off base overseas for years at a time.[10] Also, because of the
86
Third culture kid

self-sufficiency of military bases and the distinctiveness of military culture, as well as the rootless lifestyle of
moving constantly while growing up, even those military brats who never lived abroad can be isolated significantly
from the civilian regional cultures of their "home" country.
While parents of military brats had the lowest level of education of the five categories, approximately 36% of USA
military brat TCK families have at least one parent with an advanced degree. This is significantly higher than the
general population.[5]
Non-military government
Nonmilitary government TCKs are the most likely to have extended experiences in foreign countries for extended
periods. 44% have lived in at least four countries. 44% will also have spent at least 10 years outside of their passport
country. Their involvement with locals and others from their passport country depends on the role of the parent.
Some may grow up moving from country to country in the diplomatic corps (see Foreign Service Brat) while others
may live their lives near military bases.[12]
Religious
Missionary Kids (MKs) typically spend the most time overseas, of any TCKs, in one country. 85% of MKs spend
more than 10 years in foreign countries and 72% lived in only one foreign country. Of all TCKs, MKs generally
have the most interaction with the local populace and the least interaction with people from their passport country.
They are also the most likely of the TCKs to integrate themselves into the local culture.[12] 83% of missionary kids
have at least one parent with an advanced degree.[5]
Business
Business families also spend a great deal of time in foreign countries. 63% of business TCKs have lived in foreign
countries at least 10 years but are more likely than MKs to live in multiple countries. Business TCKs will have a
fairly high interaction with their host nationals and with others from their passport country.[12] Many of these
"business" families are from oil companies, particularly in the Arab world and in Latin America. Parents who work
in the pharmaceutical business typically move to countries such as Switzerland, Singapore, India, China, Japan, or
USA.
Other
TCK families who do not fit one the above categories include those employed by intergovernmental agencies (for
example, the Nuclear Energy Agency, the Commonwealth Secretariat, and the International Agency of the
Francophonie), international non-governmental organizations (for example, international schools), and local
organizations such as hospitals. Other professions include the media and athletics (for example, Wally
Szczerbiak).[13] This group typically has spent the least amount of time in foreign countries (42% are abroad for 12
years and 70% for less than 5). Again, their involvement with local people and culture can vary greatly.[12] TCKs in
this category also might live in an area with a certain ethnic majority other than their own, e.g. an Americanized
Arab Muslim living in Chinatown.
TCK parents in this category are the most likely (89%) to hold an advanced degree.[14]
87
Third culture kid
Non-American third culture kids

Most international TCKs are expected to speak English and some countries require their expatriate families to be
proficient with the English language.[10] This is largely because most international schools use the English language
as the norm.[10]
Families tend to seek out schools whose principal languages they share, and ideally one which mirrors their own
educational system. Many countries have American schools, French schools, British schools, German Schools and
'International Schools' which often follow one of the three International Baccalaureate programs. These will be
populated by expatriates' children and some children of the local upper middle class. They do this in an effort to
maintain linguistic stability and to ensure that their children do not fall behind due to linguistic problems. Where
their own language is not available, families will often choose English-speaking schools for their children. They do
this because of the linguistic and cultural opportunities being immersed in English might provide their children when
they are adults, and because their children are more likely to have prior exposure to English than to other
international languages. This poses the potential for non-English speaking TCKs to have a significantly different
experience from U.S. TCKs.[9] Research on TCKs from Japan, Denmark, Italy, Germany, the United States and
Africa has shown that TCKs from different countries share more in common with other TCKs than they do with their
own peer group from their passport country.[9]
A few sociologists studying TCKs, however, argue that the commonality found in international TCKs is not the
result of true commonality, but rather the researcher's bias projecting expectations upon the studied subculture. They
believe that some of the superficial attributes may mirror each other, but that TCKs from different countries are
really different from one another.[9] The exteriors may be the same, but that the understanding of the world around
them differs.[10]
Kikokushijo
In Japan, the use of the term "third culture kids" to refer to children returned from living overseas is not universally
accepted; they are typically referred to both in Japanese and in English as kikokushijo, literally "returnee children", a
term which has different implications. Public awareness of kikokushijo is much more widespread in Japan than
awareness of TCKs in the United States, and government reports as early as 1966 recognised the need for the school
system to adapt to them. However, views of kikokushijo have not always been positive; in the 1970s, especially, they
were characterised in media reports and even by their own parents as "educational orphans" in need of "rescue" to
reduce their foreignness and successfully reintegrate them into Japanese society.[15]
Intercultural experiences
Many TCKs take years to readjust to their passport countries. They often suffer a reverse culture shock upon their
return, and are often perpetually homesick for their adopted country. Many third culture kids face an identity crisis:
they don't know where they come from. It would be typical for a TCK to say that he is a citizen of a country, but
with nothing beyond his passport to define that identification for him. Such children usually find it difficult to
answer the question, "Where are you from?" Compared to their peers who have lived their entire lives in a single
culture, TCKs have a globalized culture. Others can have difficulty relating to them. It is hard for TCKs to present
themselves as a single cultured person, which makes it hard for others who have not had similar experiences to
accept them for who they are. They know bits and pieces of at least two cultures, yet most of them have not fully
experienced any one culture making them feel incomplete or left out by other children who have not lived overseas.
They often build social networks among themselves and prefer to socialize with other TCKs.
Many choose to enter careers that allow them to travel frequently or live overseas, which may make it seem difficult
for TCKs to build long-term, in-depth relationships. There are, however, a growing number of online resources to
help TCKs deal with issues as well as stay in contact with each other. Recently, blogs and social networks including
88
Third culture kid
89
MySpace, Facebook and TCKID, have become a helpful way for TCKs to interact. In addition, chatting programs
including MSN Messenger, AIM, and Skype are often used so TCKs can keep in touch with each other. The unique
experiences of TCKs among different cultures and various relationships at the formative stage of their development
makes their view of the world different from others.
They tend to get along with people of any culture, and develop a chameleon-like ability to become part of other
cultures. Some TCKs may also isolate themselves within their own sub-culture, sometimes excluding native children
attending their schools, or defining themselves in relation to some "other" ethnic or religious group.
As third culture kids mature they become adult third culture kids (ATCKs). Some ATCKs come to terms with issues
such as culture shock and a sense of not belonging while others struggle with these for their entire lives.
Career decisions
[16]
Missionary
Military
Government
Business
Other
Executive/Admin
17%
40%
35%
10%
24%
Semi/Professional
61%
34%
38%
47%
53%
Support (Secretarial/Technical) 17%
27%
15%
16%
13%
Sales
5%
6%
7%
5%
4%
Other
1%
4%
5%
6%
6%
Type of Work
[17]
Missionary
Military
Government
Business
Other
Business/Financial
22%
32%
27%
20%
17%
Education
25%
23%
17%
17%
28%
Health/Social Services
24%
7%
13%
23%
13%
Self Employed
11%
14%
14%
14%
14%
Government
3%
5%
5%
7%
8%
Military
2%
10%
6%
1%
2%
Non-Medical Professional 3%
6%
12%
11%
10%
Arts/Media
0%
3%
5%
4%
7%
Religious
10%
0%
0%
2%
1%
Work Setting
Statistics (U.S. TCKs)

Research has been done on American TCKs to identify various characteristics:[11] [18] [19]
Sociopsychology
90% feel "out of sync" with their peers.[20]

90% report feeling as if they understand other people and cultural groups better than the average American.[21]
80% believe they can get along with anybody, and they often do, due to their sociocultural adaptability.[21]
Divorce rates among TCKs are lower than the general population, but TCKs marry at an older age (25+).[22] [23]
More welcoming of others into their community.[19]
Lack a sense of "where home is", but are often nationalistic.[19] [21]
Third culture kid
Cognitive and emotional development

Teenage TCKs are more mature than non-TCKs, but in their twenties take longer than their peers to focus their
aims.[20]
Depression is comparatively prevalent among TCKs.[20]
TCKs' sense of identity and well-being is directly and negatively affected by repatriation.[24]
TCKs are highly linguistically adept (not as true for military TCKs).[22]
A study whose subjects were all "career military brats"those who had a parent in the military from birth
through high schoolshows that brats are linguistically adept.[25]
Like all children, TCKs may experience stress and even grief from the relocation experience.[26] [27]
Education and career
TCKs are 4 times as likely as non-TCKs to earn a bachelor's degree (81% vs 21%)[28]
40% earn an advanced degree (as compared to 5% of the non-TCK population.)[22]
45% of TCKs attended three universities before attaining a degree.[22]
44% earned undergraduate degree after the age of 22.[22]
Education, medicine, business management, self-employment, and highly-skilled positions are the most common
professions for TCKs.[22]
TCKs are unlikely to work for big business, government, or follow their parents' career choices. "One won't find
many TCKs in large corporations. Nor are there many in government ... they have not followed in parental
footsteps".[22]
Notes
[1] Useem, Ruth H.. "Third Culture Kids: Focus of Major Study" (http:/ / www. tckworld. com/ useem/ art1. html). Article 1. TCKWorld. .
[2] Pollock, David C.; Van Reken, Ruth E. (2009). Third culture kids: growing up among worlds, Rev. Ed. (http:/ / books. google. com. au/
books?id=eYK8vsA8K8MC& lpg=PP1& dq=third culture kid& pg=PA13#v=onepage& q=third culture kid& f=false). London: Nicholas
Brealey. p.13. ISBN978-1857885255. .
[3] Eakin, Kay (1998). "According to my passport, Im coming home" (http:/ / www. state. gov/ documents/ organization/ 2065. pdf). U.S. Dept
of State. p. 18. .
[4] Hyml, Annika (2002). 'Other' Expatriate Adolescents: A Postmodern Approach to Understanding Expatriate Adolescents among non-U.S.
Children, in 'Military Brats and Other Global Nomads', M. Ender, ed. (http:/ / www. transition-dynamics. com/ milbrats. html). Portland:
Greenwood. pp.196, 201. ISBN9780275972660. .
[5] Cottrell, Ann (2002). Educational and Occupational Choices of American Adult Third Culture Kids, in 'Military Brats and Other Global
Nomads', M. Ender, ed. (http:/ / www. transition-dynamics. com/ milbrats. html). Greenwood. p.230. ISBN9780275972660. .
[6] Ruth Useem's obituary in Footnotes, the Newsletter of the American Sociological Association (http:/ / www2. asanet. org/ footnotes/ dec03/
departments. html), December 2003. Retrieved 2010-01-18.
[7] http:/ / www. tckworld. com/ useem/ art1. html
[8] Ender, Morten (2002). Beyond Adolescence: The Experiences of Adult Children of Military Parents, in 'Military Brats and Other Global
Nomads', M. Ender, ed. (http:/ / www. transition-dynamics. com/ milbrats. html). Portland: Greenwood. p.xxv. ISBN9780275972660. .
[9] Hylm, Annika (2002). Other Expatriate Adolescents: A Postmodern Approach to Understanding Expatriate Adolescents Among Non-U.S.
Children, in 'Military Brats and Other Global Nomads', M. Ender, ed. (http:/ / www. transition-dynamics. com/ milbrats. html). Portland:
Greenwood. pp.196, 201. ISBN9780275972660. .
[10] Pearce, Richard (2002). Children's International Relocation and the Development Process, in 'Military Brats and Other Global Nomads', M.
Ender, ed. (http:/ / www. transition-dynamics. com/ milbrats. html). Portland: Greenwood. pp.157, 168170. ISBN9780275972660. .
[11] McCaig, Norma (1994). "Growing up with a world view - nomad children develop multicultural skills" (http:/ / www. kaiku. com/ nomads.
html). Foreign Service Journal: 3241. .
[12] Cotrell (2002) p 231
[13] Jordan (2002) p 227.
[14] Cottrell (2002) p 233-234. In the study, military dependents were the "most representative of the United States population". Over all, 80% of
TCK families had at least one parent with a BA. In 46% of TCK families an advanced degree was held by the father, and in 18% by the
mother. p 234.
[15] Kano Podolsky, Momo (2004-01-31). "Crosscultural upbringing: A comparison of the "third culture kids" framework and
"Kaigai/Kikokushijo" studies" (http:/ / www. cs. kyoto-wu. ac. jp/ bulletin/ 6/ kanou. pdf) (PDF). Gendai Shakai Kenky 6: 6778. . Retrieved
90
Third culture kid

2007-11-08.
[16] Cotrell (2002) p237
[17] Cotrell (2002) p238
[18] Useem RH (2001). Third Culture Kids: Focus of Major Study (http:/ / www. iss. edu/ pages/ kids. html). International Schools Services.
[19] Lewis L. Third Culture Kids (http:/ / wanjennifer. tripod. com/ ).
[20] Cottrell AB, Useem RH (1993). TCKs Experience Prolonged Adolescence (http:/ / www. tckworld. com/ useem/ art3. html). International
Schools Services, 8(1).
[21] Cottrell AB, Useem RH (1993). ATCKs have problems relating to their own ethnic groups (http:/ / www. tckworld. com/ useem/ art4. html).
International Schools Services, 8(2).
[22] Cottrell AB, Useem RH (1994). TCKs maintain global dimensions throughout their lives (http:/ / www. tckworld. com/ useem/ art5. html).
International Schools Services, 8(4).
[23] Jordan (2002) p.223
[24] Plamondon, Laila (2008). Third Culture Kids: Factors that Predict Psychological Health after Repatriation. Honors Thesis, Smith College.
[25] Ender, Morten, "Growing up in the Military" in Strangers at Home: Essays on the effects of living overseas and Coming 'home' to a strange
land. Edited Carolyn Smith, Alethia Publications: New York. 1996. p88-90
[26] Sheppard, Caroline H.; William Steele (2003). "Moving Can Become Traumatic" (http:/ / www. tlcinst. org/ Moving. html). Trauma and
Loss: Research and Interventions. Nat'l Inst for Trauma and Loss in Children. . Retrieved 22 January 2010.
[27] Oesterreich, Lesia (April 2004). "Understanding children: moving to a new home" (http:/ / www. extension. iastate. edu/ Publications/
PM1529G. pdf). Iowa State University. . Retrieved 22 January 2010.
[28] Cottrell AB, Useem RH (1993). TCKs Four Times More Likely to Earn Bachelors Degrees (http:/ / www. tckworld. com/ useem/ art2.
html). International Schools Services, 7(5).
References & Further Reading

Blair, Admiral Dennis, Commander in Chief, U.S. Pacific Command. "The Military Culture as an Exemplar of
American Qualities" (http://www.pacom.mil/speeches/sst2000/milchild.htm) Prepared for Supporting the
Military Child Annual Conference, Westin Horton Plaza Hotel, San Diego, California, (July 19, 2000). Retrieved
December 3, 2006.
Britten, Samuel (November 30, 1998) TCK World: A Comparison of Different "Versions" Of TCKs (http://
www.tckworld.com/comparisons.html) Third Culture Kid World. Retrieved December 3, 2006
Cottrell, Ann and Ruth Hill Useem (1993). TCKs Experience Prolonged Adolescence (http://www.tckworld.
com/useem/art3.html). International Schools Services, 8(1) Accessed January 5, 2007.
Eakin, Kay (1996). "You can't go 'Home' Again" in Strangers at Home: Essays on the effects of living overseas
and Coming 'home' to a strange land. Edited Carolyn Smith, Alethia Publications: New York. 1996
Ender, Morten, "Growing up in the Military" in Strangers at Home: Essays on the effects of living overseas and
Coming 'home' to a strange land. Edited Carolyn Smith, Alethia Publications: New York. 1996
Graham, Cork (2004) "The Bamboo Chest: An Adventure in Healing the Trauma of War" (http://www.amazon.
com/dp/0970358016) DPP 2004
Hess DJ (1994). The Whole World Guide to Culture Learning. Intercultural Press, Yarmouth, ME.
Hervey, Emily (2009). "Cultural Transitions During Childhood and Adjustment to College" (http://
worldwidefamilies.org/Documents/JPC Article_Emily_Hervey.pdf)
Jordan, Kathleen Finn (2002). "Identity Formation and the Adult Third Culture Kid " In Morten Ender, ed.,
Military Brats and Other Global Nomads.
Kalb R and Welch P (1992). Moving Your Family Overseas. Intercultural Press, Yarmouth, ME.
Kelley, Michelle (2002). The Effects of Deployment on Traditional and Nontraditional Military Families: Navy
Mothers and Their Children in Morten Ender, ed., Military Brats and Other Global Nomads
Kidd, Julie and Linda Lankenau (Undated) Third Culture Kids: Returning to their Passport Country (http://
www.state.gov/m/dghr/flo/rsrcs/pubs/4597.htm) US Department of State. Retrieved December 3, 2006.
Kohls RL (1996). Survival Kit for Overseas Living. Intercultural Press, Yarmouth, ME.
Morten G. Ender, ed. (2002). Military Brats and Other Global Nomads: Growing Up in Organization Families,
Westport, Connecticut: Praeger. ISBN 0-275-97266-6
Pascoe R (1993). Culture Shock: Successful Living Abroad. Graphic Arts, Portland, OR.
91
Third culture kid

Pearce, (2002). Children's International Relocation and the Development Process. in Morten Ender, ed., Military
Brats and Other Global Nomads
Plamondon, Laila. (2008). Third Culture Kids: Factors that Predict Psychological Health after Repatriation.
Honors Thesis, Smith College.
Pollock DC and Van Reken R (2001). Third Culture Kids. Nicholas Brealey Publishing/Intercultural Press.
Yarmouth, Maine. ISBN 1-85788-295-4.
Price, Phoebe. (2002). Behavior of Civilian and Military High School Students in Movie Theaters, in Morten
Ender, ed., Military Brats and Other Global Nomads.
Reken, Ruth (1996). Religious Culture Shock. in Carolyn Smith "STrangers at Home: Essays on The effects of
Living Overseas amd Coming Home/"
Reken, Ruth and Paulette Bethel, Third Culture Kids: Prototypes for Understanding Other Cross-Cultural Kids
(http://www.crossculturalkid.org/cck.htm) Retrieved December 3, 2006.
Seelye HN, Wasilewski JH (1996). Between Cultures: Developing Self-Identity in a World of Diversity.
McGraw-Hill Companies. ISBN 0-8442-3305-6.
Shames GW (1997). Transcultural Odysseys: The Evolving Global Consciousness. Intercultural Press, Yarmouth,
ME.
Stalnaker, Stan (2002) "Hub Culture: The Next Wave of Urban Consumers", Wiley. ISBN 978-0-470-82072-8
Storti C (1997). The Art of Coming Home. Intercultural Press, Yarmouth, ME.
Smith, Carolyn (ed) (1996). World Citizens and "Rubberband Nationals" in Carolyn Smith Strangers at Home:
Essays on the Effects of Living Overseas and Coming 'Home' to a Strange Land, New York: Aletheia
Publications. ISBN 0-9639260-4-7
Tyler, Mary (2002). The Military Teenager in Europe: Perspectives for Health care Providers, in Morten Ender,
ed., Military Brats and Other Global Nomads.
Useem, Ruth et al. (undated) Third Culture Kids: Focus of Major Study. (http://www.iss.edu/pages/kids.
html) International Schools Services. Retrieved December 3, 2006.
Van Reken, Ruth and Bethel, Paulette M. Third Culture Kids: Prototypes for Understanding Other
Cross-Cultural Kids. (http://www.crossculturalkid.org/cck.htm) Retrieved December 3, 2006.
Wertsch, Mary Edwards (1991). Military Brats: Legacies of Childhood Inside the Fortress, New York, New
York: Harmony Books. ISBN 0-517-58400-X
Williams, Karen and LisaMarie Mariglia, (2002) Military Brats: Issues and Associations in Adulthood in
Morten Ender, ed., Military Brats and Other Global Nomads
External links
TCK World (http://www.tckworld.com) Official Home of Dr. Hill Useem's research, sociologist who coined
the term "Third Culture Kid"
Third Culture Kids on ABC News (http://www.abc.net.au/rn/lifematters/stories/2009/2583257.htm) An
interview with Ruth Van Reken, Brice Royer, and Daniela Tudor from TCKID
Worldwide Families | Third Culture Kids (http://worldwidefamilies.org/ThirdCultureKids.aspx) Recent
research and current resources
Military Brats Registry (http://www.militarybrat.com/), (Social media site for military brats)
Denizen Magazine (http://www.denizenmag.com/), Online magazine created by and dedicated to TCKs
92

Adoption is an arrangement by which a child whose biological parents are unable to care for it is "adopted" and
given the same legal and social status as though he/she were the biological child of the adoptive parents. For
example, under a system of adoption, if a parent dies intestate, the adopted child stands in exactly the same position
regarding inheritance as a biological child. In adoption systems, the child can also inherit the parent's hereditary
rank. Thus, in pre-modern Japan, which had a system of true adoption, a child could inherit the parent's aristocratic
title or samurai rank, whereas in England, which only introduced legal adoption in 1926, only a biological child
could inherit an aristocratic title. This does not negate the fact that English families often reared, cared for, loved and
provided for parentless children. It is only to point out that adoption is a specific legal arrangement within the many
kinds of wardship or guardianship or fostering practiced worldwide. While all societies make provision for the
rearing of children whose own parents are unavailable to rear them, not all cultures use adoption.
Arab
Traditionally in Arab cultures if a child is adopted he or she does not become a son or daughter, but rather a ward
of the adopting caretaker(s). The childs family name is not changed to that of the adopting parent(s) and his or her
guardians are publicly known as such. Legally, this is close to other nations' systems for foster care. Other common
rules governing adoption in Islamic culture address inheritance, marriage regulations, and the fact that adoptive
parents are considered trustees of another individual's child rather than the child's new parents.[1] In addition, Islamic
countries such as Iraq and Malaysia have prohibitions against a child of Muslim parents being adopted by
non-Muslim individuals.[2] [3]
Korea
In traditional Korean culture, adoption almost always occurred when another family member (sibling or cousin)
gives a male child to the first-born male heir of the family. Adoptions outside the family were rare. This has also
been the reason why most orphaned Korean children have been exported to countries such as the United States. This
is also true to varying degrees in other Asian societies. To this day orphanages are still common all over South
Korea.
Africa
On the other hand, in many African cultures, children are often given to adoptive families. By placing a child in
another family's home, the birth family seeks to create enduring ties with the family that is now rearing the child.
The placing family may receive another child from that family, or from another. Like the reciprocal transfer of brides
from one family to another, these adoptive placements are meant to create enduring connections and social solidarity
among families and lineages.
India
There is no uniform adoption law in India; however, this statement could be debated. The Hindu Adoption and
Maintenance Act of 1956 allows only Hindus, Sikhs, Jains, and Buddhists to adopt. Muslims, Christians, Jews and
Parsees can become only guardians under the Guardians and Wards Act of 1890. Guardianship expires once the
child attains the age of 18 years.[4] For children adopted outside India, guardianship is awarded with the expectation
that the child will be quickly adopted by the adopted parents in the country where they legally reside. The Indian
government regulates domestic and inter-country adoption of children in India.[5]
93
Polynesia
Fluid adoption [6] is common in Polynesian culture, and rarely are ties to the biological family severed, as
traditionally has occurred in Western adoptions. Many Europeans and Americans associate adoption as a solution to
something gone wrong, e.g. unwanted pregnancy (by genetic parent) or infertility (by adoptive parent). By contrast,
some Polynesian cultures, for example in Sikaiana, prefer that children move between different households.
Fosterage is viewed as a way to create and maintain close personal relations, and parents traditionally do not refuse
to let others take their children. These transfers of children between different caretakers and households are not
exclusive, and they do not permanently separate the children from their biological parents.[7]
New Zealand Mori have a form of traditional adoption practised within extended family called whngai literally
meaning to feed.[8] Ties to the biological family are not normally severed.
Tahitians practice faaamu adoption (meaning literally giving to eat adoption). Its basic functions compare to the
ones of other traditional adoption practices, notably in Africa; a child can be given with the agreement or on the
initiative of the family council for a variety of reasons, they can even be asked for and given before birth.[9]
Tikopia
Traditional Tikopia (Solomon Islands) society did not practice adoption as it is traditionally understood in Western
societies. It was not uncommon for families to rear children left parentless, and childless adults would sometimes
take the child of another family and bring it up. The children, however, retained the tribal affiliation of their
biological fathers, and inherited land only from the property of the paternal lineage, not from the property of the
lineage of the guardian.[10]
References
[1] Adoption in Islam (http:/ / islam. about. com/ cs/ parenting/ a/ adoption. htm)
[2] Adoption obstacles - Blogging Baghdad: The Untold Story - MSNBC.com (http:/ / onthescene. msnbc. com/ baghdad/ 2006/ 06/
adoption_obstac. html)
[3] FAQ on Adoption (http:/ / www. jpn. gov. my/ BI/ 4_2_anakangkat. php) - National Registration Department of Malaysia. ( archived version
2006 (http:/ / web. archive. org/ web/ 20061202134315/ http:/ / www. jpn. gov. my/ FAQ-child+ adopted. htm))
[4] News from India (http:/ / indiaenews. com/ 2006-06/ 11324-indias-archaic-adoption-needs-overhaul. htm)
[5] http:/ / www. adoptionindia. nic. in
[6] Bourgeois, M.; Malarrive, J. (May 1976), "Fa'a'mu and Fanau. Various traditional aspects and current problems of adoption and donation of
children in French Polynesia", Annales Medico-Psychologiques 1 (5): 72137, PMID970828
[7] Donner, William W. (1999), "Sharing and Compassion: Fosterage in a Polynesian Society" (http:/ / www. questia. com/ googleScholar.
qst?docId=5001854512), Journal of Comparative Family Studies 30,
[8] Te Whanake Dictionary, entry for whngai (http:/ / www. maoridictionary. co. nz/ index. cfm?dictionaryKeywords=whngai)
[9] Scotti, Daria Michel, Crossing worlds (Dun monde lautre) Reflection on customary adoption practices (http:/ / www. childsrights. org/
html/ site_en/ index. php?subaction=showfull& id=1223651301& archive=& start_from=& ucat=2& ),
[10] Firth, Raymond, "We the Tikopia, Beacon Press Edition, 1936, 1957, 1963, .pp 190-193
94
95

Child development stages describe theoretical milestones of child development. Many stage models of
development have been proposed, used as working concepts and in some cases asserted as nativist theories.
This article puts forward a general model based on the most widely accepted developmental stages. However, it is
important to understand that there is wide variation in terms of what is considered "normal," driven by a wide variety
of genetic, cognitive, physical, family, cultural, nutritional, educational, and environmental factors. Many children
will reach some or most of these milestones at different times from the norm.
Overview of motor, speech, vision and hearing development

Developmental Milestones[1]
Age
Motor
Speech
Vision and hearing
46weeks
Additional Notes
Smiles at parent
68weeks
Vocalizes
1220weeks
Hand regard:
following the hand
[2]
with the eyes.
Serves to practice emerging visual

[3]
skills. Also observed in blind
[2]
children.
Follows dangling
toy from side to
side. Turns head
round to sound
Squeals with delight appropriately.

Discriminates smile.
3months
Prone:head held up for prolonged periods.

No grasp reflex
Makes vowel noises
5months
Holds head steady. Goes for objects and

gets them. Objects taken to mouth
Enjoys vocal play
6months
Transfers objects from one hand to the

other. Pulls self up to sit and sits erect with
supports. Rolls over prone to supine.
Palmar grasp of cube
Double syllable
sounds such as
'mumum' and 'dada'
Localises sound
45cm lateral to
either ear
May show 'stranger shyness'
910months Wiggles and crawls. Sits unsupported.

Picks up objects with pincer grasp
Babbles tunefully
Looks for toys

dropped
Apprehensive about strangers
1year
Stands holding furniture. Stands alone for a

second or two, then collapses with a bump
Babbles 2 or 3 words
repeatedly
Drops toys, and

watches where they
go
Cooperates with dressing, waves

goodbye, understands simple
commands
18months
Can walk alone. Picks up toy without

'Jargon'. Many
falling over. Gets up/down stairs holding
intelligible words
onto rail. Begins to jump with both feet.
Can build a tower of 3 or 4 cubes and throw
a ball
Demands constant mothering. Drinks

from a cup with both hands. Feeds self
with a spoon. Most children with
autism are diagnosed at this age.
2years
Able to run. Walks up and down stairs

2feet per step. Builds tower of 6 cubes
Joins 23 words in
sentences
Parallel play. Dry by day
3years
Goes up stairs 1-foot per step and

downstairs 2feet per step. Copies circle,
imitates cross and draws man on request.
Builds tower of 9 cubes
Constantly asks
questions. Speaks in
sentences.
Cooperative play. Undresses with

assistance. Imaginary companions
4years
Goes down stairs one foot per step, skips on Questioning at its
one foot. Imitates gate with cubes, copies a height. Many infantile
cross
substitutions in speech
Dresses and undresses with assistance.

Attends to own toilet needs
96
5years
Skips on both feet and hops. Draws a man

and copies a triangle. Gives age
Fluent speech with

few infantile
substitutions in speech
6years
Copies a diamond. Knows right from left

and number of fingers
Fluent speech
Dresses and undresses alone
Physical specifications
Age
Average
length/height
(cm)
Length
growth
14months
5070 cm (2028
in)
2.5cm
(0.98in) per
month
48 kg (8.818
lb)
100200g
per week
30 to 40
35.737.5 C
48months
7075 cm (2830
in)
1.3cm
(0.51in) per
month
(doubling birth
weight)
500g per
month
25 to 50
body
temperature
heart rate
812months
Approx. 1.5 times

birth length by first
birthday
body
temperature
9.6kg (21lb)
Nearly triple the
birth weight by
first birthday
500g per
month
20 to 45
body
temperature
heart rate
20/100
130250g
per month
22 to 40
body
temperature
80 to 110
20/60
713 cm
1215 kg (2633 1kg per year 20 to 35
(2.85.1 in) per lb)
year
about 4 times
birth weight
body
temperature
heart rate
1224months 8090 cm (3135

in)
2years
8595 cm (3337
in)
Average weight
58 cm
913 kg (2029
(2.03.1 in) per lb)
year
Weight
gain
Respiration
rate
(per minute)
Normal body
temperature
Heart
rate
(pulse)
(per
minute)
Visual
acuity
(Snellen
chart)
Specifications sorted by reached age

14months
Physical
Head and chest circumference are nearly equal to the part of the abdomen.
Head circumference increases approximately 2cm per month until two months, then increases 1.5cm per month
until four months.
Increases are an important indication of continued brain growth.
Continues to breathe using abdominal muscles.
Posterior fontanelle.
Anterior fontanelle.
Skin remains sensitive and easily irritated.
Legs.
Cries with tears.
Gums are red.
Eyes begin moving together in unison (binocular vision).

Motor development
Rooting and sucking reflexes are well developed.

Swallowing reflex and tongue movements are immature;inability to move food to the back of the mouth.
Grasp reflex.
Landau reflex appears near the middle of this period; when baby is held in a prone (face down) position, the head
is held upright and legs are fully extended.
Grasps with entire hand; strength insufficient to hold items. Holds hands in an open or semi-open position.
Movements are large and jerky.
Raises head and upper body on arms when in a prone position.
Turns head side to side when in a supine (face up) position;can not hold head up and line with the body.
Upper body parts are more active: clasps hands above face, waves arms about, reaches for objects.
48months
Physical
Head and chest circumferences are basically equal.
Head circumference increases approximately 1cm per month until six to seven months, then 0.5cm per month;
head circumference should continue to increase steadily, indicating healthy, ongoing brain growth.
Posterior fontanelle closing or fully closed.
Anterior fontanelle.
Breathing is abdominal; respiration rate depending on activity; rate and patterns vary from infant to infant.
Teeth may begin to appear, with upper and lower incisors coming in first. Gums may become red and swollen,
accompanied by increased drooling, chewing, biting, and mouthing of objects.
Legs may appear bowed; bowing gradually disappears as infant grows older.
Fat rolls ("Baby Fat") appear on thighs, upper arms and neck.
True eye color is established.
Motor development
Reflexive behaviors are changing:

Blinking reflex is well established
Sucking reflex becomes voluntary
Moro reflex disappears
When lowered suddenly, infant throws out arms as a protective measure.
Swallowing reflex appears and allows infant to move solid foods from front of mouth to the back for swallowing.
Picks up objects using finger and thumb (pincer grip).
Reaches for objects with both arms simultaneously; later reaches with one hand or the other.
Transfers objects from one hand to the other; grasps object using entire hand (palmar grasp).
Handles, shakes, and pounds objects; puts everything in mouth.
Able to hold bottle.
Sits alone without support, holding head erect, back straightened, and arms propped forward for support
Pulls self into a crawling position by raising up on arms and drawing knees up beneath the body; rocks back and
forth, but generally does not move forward.
Lifts head when placed on back.
Can roll over from back or stomach position.
May accidentally begin scooting backwards when placed on stomach; soon will begin to crawl forward.
Looks for fallen objects by 7months
Plays peek-a-boo games
97

Cannot understand no or danger
812Months
Physical
Respiration rates vary with activity

Environmental conditions, weather, activity, and clothing still affect variations in body temperature.
Head and chest circumference remain equal.
Anterior fontanelle begins to close.
Continues to use abdominal muscles for breathing.
More teeth appear, often in the order of two lower incisors then two upper incisors followed by four more incisors
and two lower molars but some babies may still be waiting for their first.
Arm and hands are more developed than feet and legs (cephalocaudal development); hands appear large in
proportion to other body parts.
Legs may continue to appear bowed.
"Baby Fat" continues to appear on thighs, upper arms and neck.
Feet appear flat as arch has not yet fully developed.
Both eyes work in unison (true binocular coordination).

Can see distant objects (4 to 6 mor 13 to 20 ft away) and points at them.
Motor development
Reaches with one hand leading to grasp an offered object or toy.

Manipulates objects, transferring them from one hand to the other.
Explores new objects by poking with one finger.
Uses deliberate pincer grasp to pick up small objects, toys, and finger foods.
Stacks objects; also places objects inside one another.
Releases objects or toys by dropping or throwing; cannot intentionally put an object down.
Beginning to pull self to a standing position.
Beginning to stand alone, leaning on furniture for support; moves around obstacles by side-stepping.
Has good balance when sitting; can shift positions without falling.
Creeps on hands and knees; crawls up and down stairs.
Walks with adult support, holding onto adult's hand; may begin to walk alone.
Watches people, objects, and activities in the immediate environment.
Shows awareness of distant objects (4 to 6 mor 13 to 20 ft away) by pointing at them.
Responds to hearing tests (voice localization); however, loses interest quickly and, therefore, may be difficult to
test formally.
Follows simple instructions.
Reaches for toys that are out of reach but visible
Recognizes objects in reverse
Drops thing intentionally and repeats and watches object
Imitates activities like playing drum
98
Toddlers (1224months)
Physical
Weight is now approximately 3 times the child's birth weight.

Respiration rate varies with emotional state and activity.
Rate of growth slows
Head size increases slowly; grows approximately 1.3cm every six months; anterior fontanelle is nearly closed at
eighteen months as bones of the skull thicken.
Anterior fontanelle closing or fully closed, usually at the middle of this year.
Chest circumference is larger than head circumference.
Legs may still appear bowed.
Toddler will begin to lose the "Baby Fat" once he/she begins walking.
Body shape changes; takes on more adult-like appearance; still appears top-heavy; abdomen protrudes, back is
swayed.
Motor development
Crawls skillfully and quickly.
Stands alone with feet spread apart, legs stiffened, and arms extended for support.
Gets to feet unaided.
Most children walk unassisted near the end of this period; falls often; not always able to maneuver around
obstacles, such as furniture or toys.
Uses furniture to lower self to floor; collapses backwards into a sitting position or falls forward on hands and then
sits.
Enjoys pushing or pulling toys while walking.
Repeatedly picks up objects and throws them; direction becomes more deliberate.
Attempts to run; has difficulty stopping and usually just drops to the floor.
Crawls up stairs on all fours; goes down stairs in same position.
Sits in a small chair.
Carries toys from place to place.
Enjoys crayons and markers for scribbling; uses whole-arm movement.
Helps feed self; enjoys holding spoon (often upside down) and drinking from a glass or cup; not always accurate
in getting utensils into mouth; frequent spills should be expected.
Helps turn pages in book.
Stacks two to six objects per day.
Cognitive development
Enjoys object-hiding activities
Early in this period, the child always searches in the same location for a hidden object (if the child has watched
the hiding of an object). Later, the child will search in several locations.
Passes toy to other hand when offered a second object (referred to as "crossing the midline"-an important
neurological development).
Manages three to four objects by setting an object aside (on lap or floor) when presented with a new toy.
Puts toys in mouth less often.
Enjoys looking at picture books.
Demonstrates understanding of functional relationships (objects that belong together): Puts spoon in bowl and
then uses spoon as if eating; places teacup on saucer and sips from cup; tries to make doll stand up.
Shows or offers toy to another person to look at.
99

Names many everyday objects.
Shows increasing understanding of spatial and form discrimination: puts all pegs in a pegboard; places three
geometric shapes in large formboard or puzzle.
Places several small items (blocks, clothespins, cereal pieces) in a container or bottle and then dumps them out.
Tries to make mechanical objects work after watching someone else do so.
Responds with some facial movement, but cannot truly imitate facial expression.
Most children with autism are diagnosed at this age.
Language
Produces considerable "jargon": puts words and sounds together into speech-like (inflected) patterns.
Holophrastic speech: uses one word to convey an entire thought; meaning depends on the inflection ("me" may be
used to request more cookies or a desire to feed self). Later; produces two-word phrases to express a complete
thought (telegraphic speech): "More cookie," "Daddy bye-bye."
Follows simple directions, "Give Daddy the cup."
When asked, will point to familiar persons, animals, and toys.
Identifies three body parts if someone names them: "Show me your nose (toe, ear)."
Indicates a few desired objects and activities by name: "Bye-bye," "cookie"; verbal request is often accompanied
by an insistent gesture.
Responds to simple questions with "yes" or "no" and appropriate head movement.
Speech is 25 to 50 percent intelligible during this period.
Locates familiar objects on request (if child knows location of objects).
Acquires and uses five to fifty words; typically these are words that refer to animals, food, and toys.
Uses gestures, such as pointing or pulling, to direct adult attention.
Enjoys rhymes and songs; tries to join in.
Seems aware of reciprocal (back and forth) aspects of conversational exchanges; some turn-taking in other kinds
of vocal exchanges, such as making and imitating sounds.
Social
less wary of strangers.
Helps pick up and put away toys.
Plays by themselves
Enjoys being held and read to.

Often imitates adult actions in play.
Enjoys adult attention; likes to know that an adult is near; gives hugs and kisses.
Recognizes self in mirror.
Enjoys the companionship of other children, but does not play cooperatively.
Beginning to assert independence; often refuses to cooperate with daily routines that once were enjoyable; resists
getting dressed, putting on shoes, eating, taking a bath; wants to try doing things without help.
May have a tantrum when things go wrong or if overly tired or frustrated.
Exceedingly curious about people and surroundings; toddlers need to be watched carefully to prevent them from
getting into unsafe situations.
100

Psychological
Autonomy vs. Shame and Doubt (will)
(J. Chasse, 2008) Psychosocial stimulation is vital during the toddler years. Play begins to become interactive.
Toddlers begin to learn and exhibit independence, but ironically they enjoy sharing this discovery with others.
Another important advancement is active social play with adults including mirroring and repeating. Songs, rhymes,
and finger plays (e.g. eensy weensy spider, little teapot, etc.) are a great way to encourage and stimulate this area of
development. Want attention, if not paid start throwing objects, trouble you watching TV. Scared from dark, start
crying loudly under the situation.
Two year old

Physical
Posture is more erect; abdomen still large and protruding, back swayed, because abdominal muscles are not yet
fully developed.
Respirations are slow and regular
Body temperature continues to fluctuate with activity, emotional state, and environment.
Brain reaches about 80 percent of its adult size.
16 baby teeth almost finished growing out
Motor development
Can walk around obstacles and walk more erect

Squats for long periods while playing.
Climbs stairs unassisted (but not with alternating feet).
Balances on one foot (for a few moments), jumps up and down, but may fall.
Often achieves toilet training during this year (depending on child's physical and neurological development)
although accidents should still be expected; the child will indicate readiness for toilet training.
Throws large ball underhand without losing balance. Holds small cup or tumbler in one hand. Unbuttons large
buttons; unzips large zippers.
Opens doors by turning doorknobs.
Grasps large crayon with fist; scribbles.
Climbs up on chair, turns, and sits down.
Stacks four to six objects on top of one another.
Uses feet to propel wheeled riding toys.
Cognitive
Eyehand movements better coordinated; can put objects together, take them apart; fit large pegs into pegboard.
Begins to use objects for purposes other than intended (may push a block around as a boat).
Does simple classification tasks based on single dimension (separates toy dinosaurs from toy cars).
Seems fascinated by, or engrossed in, figuring out situations: where the tennis ball rolled, where the dog went,
what caused a particular noise.
Attends to self-selected activities for longer periods of time. Discovering cause and effect: squeezing the cat
makes her scratch.
Knows where familiar persons should be; notes their absence; finds a hidden object by looking in last hiding place
first. (This is what Piaget termed object permanence, which usually occurs during the sensorimotor stage of
Piaget's childhood theory of cognitive development)
Names familiar objects.
Recognizes, expresses, and locates pain.
101

Expected to use "magical thinking", such as believing a toy bear is a real bear.
Tells about objects and events not immediately present (this is both a cognitive and linguistic advance).
Expresses more curiosity about the world.
Language
Enjoys participating while being read to.

Realizes language is effective for getting desired responses.
Uses fifty to three-hundred words; vocabulary continuously increasing.
Has broken the linguistic code; in other words, much of a two-year-old's talk has meaning to him or her.
Receptive language is more developed than expressive language; most two-year olds understand significantly
more than they can talk about.
Utters three- and four-word statements; uses conventional word order to form more complete sentences.
Refers to self as "me" or sometimes "I" rather than by name: "Me go bye-bye"; has no trouble verbalizing "mine."
Expresses negative statements by tacking on a negative word such as "no" or "not": "Not more milk."
Uses some plurals.
Some stammering and other dysfluencies are common.
Speech is as much as 65 to 70 percent intelligible.
Is able to verbalize needs.

Social and emotional
Shows signs of empathy and caring: comforts another child if hurt or frightened; appears to sometimes be overly
affectionate in offering hugs and kisses to children
Continues to use physical aggression if frustrated or angry (for some children, this is more exaggerated than for
others); Physical aggression usually lessens as verbal skills improve.
Temper tantrums likely to peak during this year; extremely difficult to reason with during a tantrum.
Impatient; finds it difficult to wait or take turns.
Enjoys "helping" with household chores; imitates everyday activities: may try to toilet a stuffed animal, feed a
doll.
"Bossy" with parents and caregivers; orders them around, makes demands, expects immediate compliance from
adults.
Watches and imitates the play of other children, but seldom interacts directly; plays near others, often choosing
similar toys and activities (parallel play);[4] solitary play is often simple and repetitive.[5]
Offers toys to other children, but is usually possessive of playthings; still tends to hoard toys.
Making choices is difficult; wants it both ways.
Often defiant; shouting "no" becomes automatic.
Ritualistic; wants everything "just so"; routines carried out exactly as before; belongings placed "where they
belong."
102
Three year old

Physical
Growth is steady though slower than in first two years.
Adult height can be predicted from measurements of height at three years of age; males are approximately 53% of
their adult height and females, 57%.
Legs grow faster than arms,
Circumference of head and chest is equal; head size is in better proportion to the body.
"Baby fat" disappears as neck appears.
Posture is more erect; abdomen no longer protrudes.
Slightly knock-kneed.
can jump from low step
can stand up and walk around on tiptoes
"baby" teeth stage over.
Needs to consume approximately 6,300J (1,500calories) daily.
Motor development
Walks up and down stairs unassisted, using alternating feet; may jump from bottom step, landing on both feet.
Can walk on one foot, balance momentarily.
Can kick big ball-shaped objects.
Needs minimal assistance eating.
Jumps on the spot.
Pedals a small tricycle.
Throws a ball overhand; aim and distance are limited.
Catches a large bounced ball with both arms extended.
Enjoys swinging on a swing (not too high or too fast).
Shows improved control of crayons or markers; uses vertical, horizontal and circular strokes.
Holds crayon or marker between first two fingers and thumb (tripod grasp), not in a fist as earlier.
Can turn pages of a book one at a time
Enjoys building with blocks.
Builds a tower of eight or more blocks.
Enjoys playing with clay; pounds, rolls, and squeezes it.
May begin to show hand dominance.
Carries a container of liquid, such as a cup of milk or bowl of water, without much spilling; pours liquid from
pitcher into another container.
Manipulates large buttons and zippers on clothing.
Washes and dries hands; brushes own teeth, but not thoroughly.
Usually achieves complete bladder control during this time.
103

Listens attentively to age-appropriate stories.

Makes relevant comments during stories, especially those that relate to home and family events.
Likes to look at books and may pretend to "read" to others or explain pictures.
Enjoys stories with riddles, guessing, and "suspense."
Speech is understandable most of the time.
Produces expanded noun phrases: "big, brown dog."
Produces verbs with "ing" endings; uses "-s" to indicate more than one; often puts "-s" on already pluralized
forms: geeses, mices.
Indicates negatives by inserting "no" or "not" before a simple noun or verb phrase: "Not baby."
Answers "What are you doing?", "What is this?", and "Where?" questions dealing with familiar objects and
events.
Four year old

Physical Development
Head circumference is usually not measured after age three.
Requires approximately 1,700calories daily.
Hearing acuity can be assessed by child's correct usage of sounds and *Language also, by the child's appropriate
responses to questions and instructions.
Motor Development
Walks a straight line (tape or chalk line on the floor).

Hops on one foot.
Pedals and steers a wheeled toy with confidence; turns corners, avoids obstacles and oncoming "traffic."
Climbs ladders, trees, playground equipment.
Jumps over objects 12 to 15 cm (5 to 6 in) high; lands with both feet together.
Runs, starts, stops, and moves around obstacles with ease.
Throws a ball overhand; distance and aim improving.
Builds a tower with ten or more blocks.
Forms shapes and objects out of clay: cookies, snakes, simple animals.
Reproduces some shapes and letters.
Holds a crayon or marker using a tripod grasp.
Paints and draws with purpose; may have an idea in mind, but often has problems implementing it so calls the
creation something else.
Becomes more accurate at hitting nails and pegs with hammer.
Threads small wooden beads on a string.
Can run in a circle
104

Cognitive
Can recognize that certain words sound similar
Names eighteen to twenty uppercase letters. Writes several letters and sometimes their name.
A few children are beginning to read simple books, such as alphabet books with only a few words per page and
many pictures.
Likes stories about how things grow and how things operate.
Delights in wordplay, creating silly Language.
Understands the concepts of "tallest," "biggest," "same," and "more"; selects the picture that has the "most
houses" or the "biggest dogs."
Rote counts to 20 or more.
Understands the sequence of daily events: "When we get up in the morning, we get dressed, have breakfast, brush
our teeth, and go to school."
When looking at pictures, can recognize and identify missing puzzle parts (of person, car, animal).
Very good storytellers.
Counts 1 to 7 objects out loud, but not always in order
follows two to three step directions given individually or in a group
may put the "ed" on the end of words such as "I goed outside and I played."
Language
Uses the prepositions "on," "in," and "under."

Uses possessives consistently: "hers," "theirs," "baby's."
Answers "Whose?", "Who?", "Why?", and "How many?"
Produces elaborate sentence structures: "The cat ran under the house before I could see what color it was."
Speech is almost entirely intelligible.
Begins to correctly use the past tense of verbs: "Mommy closed the door," "Daddy went to work."
Refers to activities, events, objects, and people that are not present.
Changes tone of voice and sentence structure to adapt to listener's level of under-standing: To baby brother, "Milk
gone?" To Mother, "Did the baby drink all of his milk?"
States first and last name, gender, siblings' names, and sometimes own telephone number.
Answers appropriately when asked what to do if tired, cold, or hungry. Recites and sings simple songs and
rhymes.
Social development
Outgoing; friendly; overly enthusiastic at times.
Moods change rapidly and unpredictably; laughing one minute, crying the next; may throw tantrum over minor
frustrations (a block structure that will not balance); sulk over being left out.
Imaginary playmates or companions are common; holds conversations and shares strong emotions with this
invisible friend.
Boasts, exaggerates, and "bends" the truth with made-up stories or claims of boldness; tests the limits with
"bathroom" talk.
Cooperates with others; participates in group activities.
Shows pride in accomplishments; seeks frequent adult approval.
Often appears selfish; not always able to take turns or to understand taking turns under some conditions; tattles on
other children.
Insists on trying to do things independently, but may get so frustrated as to verge on tantrums when problems
arise: paint that drips, paper airplane that will not fold right.
Enjoys role-playing and make-believe activities.
105

Relies (most of the time) on verbal rather than Physical aggression; may yell angrily rather than hit to make a
point; threatens: "You can't come to my birthday party"
Name-calling and taunting are often used as ways of excluding other children.
Establishes close relationships with playmates; beginning to have "best" friends.
Five year old

Physical
Head size is approximately that of an adult's.

May begin to lose "baby" (deciduous) teeth.
Body is adult-like in proportion.
Requires approximately 7,500J (1,800calories) daily
Visual tracking and binocular vision are well developed.
Motor development
Walks backwards, toe to heel.
Walks unassisted up and down stairs, alternating feet.
May learn to turn somersaults (should be taught the right way in order to avoid injury).
Can touch toes without flexing knees.
Walks a balance beam.
Learns to skip using alternative feet.
Catches a ball thrown from 1m (3.3ft) away.
Rides a tricycle or wheeled toy with speed and skillful steering; some children learning to ride bicycles, usually
with training wheels.
Jumps or hops forward ten times in a row without falling.
Balances on either foot with good control for ten seconds.
Builds three-dimensional structures with small cubes by copying from a picture or model.
Reproduces many shapes and letters: square, triangle, A, I, O, U, C, H, L, T.
Demonstrates fair control of pencil or marker; may begin to color within the lines.
Cuts on the line with scissors (not perfectly).
Hand dominance is fairly well established.
Cognitive
Forms rectangle from two triangular cuts.

Builds steps with set of small blocks.
Understands concept of same shape, same size.
Sorts objects on the basis of two dimensions, such as color and form.
Sorts a variety of objects so that all things in the group have a single common feature (classification skill: all are
food items or boats or animals).
Understands the concepts of smallest and shortest; places objects in order from shortest to tallest, smallest to
largest.
Identifies objects with specified serial position: first, second, last.
Rote counts to 20 and above; many children count to 100.
Recognizes numerals from 1 to 10.
Understands the concepts of less than: "Which bowl has less water?"
Understands the terms dark, light, and early: "I got up early, before anyone else. It was still dark."
Relates clock time to daily schedule: "Time to turn on TV when the little hand points to 5."
106
Some children can tell time on the hour: five o'clock, two o'clock.
Knows what a calendar is for.
Recognizes and identifies coins; beginning to count and save money.
Many children know the alphabet and names of upper- and lowercase letters.
Understands the concept of half; can say how many pieces an object has when it's been cut in half.
Asks innumerable questions: Why? What? Where? When?
Eager to learn new things.
Language development
Vocabulary of 1,500 words plus.

Tells a familiar story while looking at pictures in a book.
Defines simple words by function: a ball is to bounce; a bed is to sleep in.
Identifies and names four to eight colours.
Recognizes the humor in simple jokes; makes up jokes and riddles.
Produces sentences with five to seven words; much longer sentences are not unusual.
States the name of own city or town, birthday, and parents' names.
Answers telephone appropriately; calls person to phone or takes a brief message
Speech is almost entirely grammatically correct.

Uses "would" and "could" appropriately.
Uses past tense of irregular verbs consistently: "went," "caught," "swam."
Uses past-tense inflection (-ed) appropriately to mark regular verbs: "jumped," "rained," "washed."
Social development
Enjoys and often has one or two focus friendships.

Plays cooperatively (can lapse), is generous, takes turns, shares toys.
Participates in group play and shared activities with other children; suggests imaginative and elaborate play ideas.
Shows affection and caring towards others especially those below them or in pain
Generally subservient to parent or caregiver requests.
Needs comfort and reassurance from adults but is less open to comfort.
Has better self-control over swings of emotions.
Likes entertaining people and making them laugh.
Boasts about accomplishments.
Six year old

Physical
Weight gains reflect significant increases in muscle mass.

Heart rate and respiratory rates are close to adults.
Body may appear lanky as through period of rapid growth.
Baby teeth beginning to be replaced by permanent ones, starting with the two lower front teeth
20/20 eyesight; if below 20/40 should see a professional.
The most common vision problem during middle childhood is myopia, or nearsightedness. (Berk, 2007).
Uses 6,700J to 7,100J (1,600 to 1,700calories) a day.
107

Motor development
Gains greater control over large and fine motor skills; movements are more precise and deliberate, though some
clumsiness persists.
Enjoys vigorous running, jumping, climbing, and throwing est.
Has trouble staying still.
Span of attention increases; works at tasks for longer periods of time, though
Can concentrate effort but not always consistently.
Understands time (today, tomorrow, yesterday) and simple motion (things go faster than others).
Recognizes seasons and major activities done in the times.
Has fun with problem solving and sorting activities like stacking, puzzles and mazes
Enjoys the challenge of puzzles, counting and sorting activities, paper-and-pencil mazes, and games that involve
matching letters and words with pictures.
Recognizes some words by sight; attempts to sound out words
In some cases the child may be reading well.
functioning which facilitates learning to ride a bicycle, swim, swing a bat, or kick a ball.
Making things is enjoyed.
Reverses or confuse certain letters: b/d, p/g, g/q, t/f.
Able to trace objects.
Folds and cuts paper into simple shapes.
Can Tie Laces, string (like shoes).
Language
Can identify right and left hands fairly consistently.

Holds onto positive beliefs involving the unexplainable (magic or fantasy)
Arrives at some understanding about death and dying; expresses fear that parents may die.
Talks a lot.
Loves telling jokes and riddles; often, the humor is far from subtle.
Experiments with slang and profanity and finds it funny.
Enthusiastic and inquisitive about surroundings and everyday events.
Able to carry on adult-like conversations; asks many questions.
Learns 5 to 10 words a day; vocabulary of 10,00014,000.
Uses appropriate verb tenses, word order, and sentence structure.
Social and emotional

Uses language rather than tantrums or physical aggression to express displeasure: "That's mine! Give it back, you
dummy."
Talks self through steps required in simple problem-solving situations (though the "logic" may be unclear to
adults).
Has mood swings towards primary caregiver depending on the day
Friendship with parent is less depended on but still needs closeness and nurturing.
Anxious to please; needs and seeks adult approval, reassurance, and praise; may complain excessively about
minor hurts to gain more attention.
Often can't view the world from anothers point of view
Self-perceived failure can make the child easily disappointed and frustrated.
Can't handle things not going their own way
Does not understand ethical behavior or moral standards especially when doing things that have not been given
rules
108

Understands when he or she has been thought to be "bad"; values are based on others enforced values.
May be increasingly fearful of the unknown like things in the dark, noises, and animals.
References
[1] Seminars in child and adolescent psychiatry (second edition) Ed. Simon G. Gowers. Royal College of Psychiatrists (2005) ISBN
1-904671-13-6
[2] http:/ / www. gpnotebook. co. uk/ simplepage. cfm?ID=-919273423
[3] http:/ / www. tsbvi. edu/ Education/ infant/ page3. htm
[4] Parten, M. (1932). Social participation among preschool children. Journal of Abnormal and Social Psychology, 27, 243269.
[5] Ruben, K. H., Fein, G. G., & Vandenberg, B. (1983). Play. In E. M. Hetherington (Ed.), Handbook of child psychology: Vol. 4. Socialization,
personality, and social development (4th ed., pp.693744). New York: Wiley.
Segal, Marilyn (1998). Your Child At Play: Three to Five Years (http:/ / www. eric. ed. gov/ ERICWebPortal/
custom/ portlets/ recordDetails/ detailmini. jsp?_nfpb=true& _& ERICExtSearch_SearchValue_0=ED425832&
ERICExtSearch_SearchType_0=no& accno=ED425832). New York: Newmarket Press. pp.292.
ISBN1-55704-337-X.
External links
CDC's "Learn the Signs. Act Early. campaign (http://www.cdc.gov/ncbddd/actearly/milestones/index.html)
Information for parents on early childhood development and developmental disabilities
Developmental Milestones (http://www.nichcy.org/Disabilities/Milestones/Pages/Default.aspx) National
Dissemination Center for Children with Disabilities, NICHCY
YourChild: Developmental Milestones (http://www.med.umich.edu/yourchild/topics/devmile.htm)
University of Michigan Health System
Talking Point (http://www.talkingpoint.org.uk) Information for parents and people that work with children,
including milestones for speech and language development in children
109
Ethology
Ethology
Ethology (from Greek: , ethos, "character"; and -, -logia, "the study of") is the scientific study of animal
behavior, and a sub-topic of zoology.
Although many naturalists have studied aspects of animal behavior throughout history, the modern discipline of
ethology is generally considered to have begun during the 1930s with the work of Dutch biologist Nikolaas
Tinbergen and Austrian biologists Konrad Lorenz and Karl von Frisch, joint winners of the 1973 Nobel Prize in
Physiology or Medicine.[1] Ethology is a combination of laboratory and field science, with a strong relation to certain
other disciplines such as neuroanatomy, ecology, and evolution. Ethologists are typically interested in a behavioral
process rather than in a particular animal group, and often study one type of behavior (e.g. aggression) in a number
of unrelated animals.
The desire to understand animals has made ethology a rapidly growing field. Since the turn of the 21st century, many
aspects of animal communication, animal emotions, animal culture, learning, and even sexual conduct that experts
long thought they understood, have been reexamined, and new conclusions reached. New fields have developed,
such as neuroethology.
Etymology
The term ethology derives from the Greek word thos (), meaning character. Other words that derive from
ethos" include ethics[2] and ethical. The term was first popularized by American myrmecologist William Morton
Wheeler in 1902.[3] An earlier, slightly different sense of the term was proposed by John Stuart Mill in his 1843
System of Logic.[4] He recommended the development of a new science, "ethology," the purpose of which would be
explanation of individual and national differences in character, on the basis of associationistic psychology. This use
of the word was never adopted.
Relationship with comparative psychology

Comparative psychology also studies animal behaviour, but, as opposed to ethology, is construed as a sub-topic of
psychology rather than as one of biology. Historically, where comparative psychology researches animal behaviour
in the context of what is known about human psychology, ethology researches animal behaviour in the context of
what is known about animal anatomy, physiology, neurobiology, and phylogenetic history. Furthermore, early
comparative psychologists concentrated on the study of learning and tended to research behaviour in artificial
situations, whereas early ethologists concentrated on behaviour in natural situations, tending to describe it as
instinctive. The two approaches are complementary rather than competitive, but they do result in different
perspectives and, sometimes, conflicts of opinion about matters of substance. In addition, for most of the twentieth
century, comparative psychology developed most strongly in North America, while ethology was stronger in Europe.
A practical difference is that early comparative psychologists concentrated on gaining extensive knowledge of the
behaviour of very few species. Ethologists were more interested in understanding behaviour in a wide range of
species to facilitate principled comparisons across taxonomic groups. Ethologists have made much more use of a
truly comparative method than comparative psychologists have. Despite the historical divergence, most ethologists,
at least in North America, teach in psychology departments. It is a strong belief among scientists that the
mechanisms on which behavioural processes are based are the same that cause the evolution of the living species:
there is therefore a strong association between these two fields.
110
Ethology
111
Scala naturae and Lamarck's theories

Until the 19th century, the most common theory among scientists
was still the concept of scala naturae, proposed by Aristotle.
According to this theory, living beings were classified on an ideal
pyramid that represented the simplest animals on the lower levels,
with complexity increasing progressively toward the top, occupied
by human beings. In the Western world of the time, people
believed animal species were eternal and immutable, created with
a specific purpose, as this seemed the only possible explanation for
the incredible variety of living beings and their surprising
adaptation to their habitats.[3]
Jean-Baptiste Lamarck (1744 - 1829) was the first biologist to
describe a complex theory of evolution. His theory substantially
comprised two statements: first, that animal organs and behaviour
can change according to the way they are used; and second, that
those characteristics can transmit from one generation to the next
(the example of the giraffe whose neck becomes longer while
trying to reach the upper leaves of a tree is well-known). The
second statement is that every living organism, humans included,
tends to reach a greater level of perfection. When Charles Darwin
went to the Galapagos Islands, he was well aware of Lamarck's
theories and was influenced by them.
Jean-Baptiste Lamarck (17441829)
Theory of evolution by natural selection and

the beginnings of ethology
Because ethology is considered a topic of biology, ethologists
have been concerned particularly with the evolution of behaviour
and the understanding of behaviour in terms of the theory of
natural selection. In one sense, the first modern ethologist was
Charles Darwin, whose book, The Expression of the Emotions in
Man and Animals, influenced many ethologists. He pursued his
Charles Darwin (18091882)
interest in behaviour by encouraging his protg George Romanes,
who investigated animal learning and intelligence using an
anthropomorphic method, anecdotal cognitivism, that did not gain scientific support.
Other early ethologists, such as Oskar Heinroth and Julian Huxley, instead concentrated on behaviours that can be
called instinctive, or natural, in that they occur in all members of a species under specified circumstances. Their
beginning for studying the behaviour of a new species was to construct an ethogram (a description of the main types
of natural behaviour with their frequencies of occurrence).[3] This provided an objective, cumulative base of data
about behaviour, which subsequent researchers could check and supplement.
Ethology
Fixed action patterns and animal communication

An important development, associated with the name of Konrad Lorenz though probably due more to his teacher,
Oskar Heinroth, was the identification of fixed action patterns (FAPs). Lorenz popularized FAPs as instinctive
responses that would occur reliably in the presence of identifiable stimuli (called sign stimuli or releasing stimuli).
These FAPs could then be compared across species, and the similarities and differences between behaviour could be
easily compared with the similarities and differences in morphology. An important and much quoted study of the
Anatidae (ducks and geese) by Heinroth used this technique. Ethologists noted that the stimuli that released FAPs
were commonly features of the appearance or behaviour of other members of the animal's own species, and they
were able to prove how important forms of animal communication could be mediated by a few simple FAPs. The
most sophisticated investigation of this kind was the study by Karl von Frisch of the so-called "dance language"
related to bee communication.[5] Lorenz developed an interesting theory of the evolution of animal communication
based on his observations of the nature of fixed action patterns and the circumstances in which animals emit them.
Instinct
The Merriam-Webster dictionary defines instinct as a largely
inheritable and unalterable tendency of an organism to make a complex
and specific response to environmental stimuli without involving
reason.[6] For ethologists, instinct means a series of predictable
behaviors for fixed action patterns. Such schemes are only acted when
a precise stimulating signal is present. When such signals act as
communication among members of the same species, they are known
as releasers. A notable example of a releaser is the beak movements in
Kelp Gull chicks peck at red spot on mother's
many bird species performed by the newborns, which stimulates the
beak to stimulate regurgitating reflex.
mother's regurgitating process to feed her offspring.[7] Another
well-known case is the classic experiments by Tinbergen on the
Graylag Goose. Like similar waterfowl, the goose rolls a displaced egg near its nest back to the others with its beak.
The sight of the displaced egg triggers this mechanism. If the egg is taken away, the animal continues with the
behaviour, pulling its head back as if an imaginary egg is still being maneuvered by the underside of its beak.[8]
However, it also attempts to move other egg-shaped objects, such as a giant plaster egg, door knob, or even a
volleyball back into the nest. Such objects, when they exaggerate the releasers found in natural objects, can elicit a
stronger version of the behavior than the natural object, so that the goose ignores its own displaced egg in favor of
the giant dummy egg. These exaggerated releasers for instincts were named supernormal stimuli by Tinbergen.[9]
Tinbergen found he could produce supernormal stimuli for most instincts in animalssuch as cardboard butterflies
that male butterflies preferred to mate with if they had darker stripes than a real female, or dummy fish that a
territorial male stickleback fish fought more violently than a real invading male if the dummy had a brighter-colored
underside. Harvard psychologist Deirdre Barrett has done research pointing out how easily humans also respond to
supernormal stimuli for sexual, nurturing, feeding, and social instincts.[10] However, a behaviour only made of fixed
action patterns would be particularly rigid and inefficient, reducing the probability of survival and reproduction, so
the learning process has great importance, as does the ability to change the individual's responses based on its
experience. It can be said that the more the brain is complex and the life of the individual long, the more its
behaviour is "intelligent" (in the sense of being guided by experience rather than stereotyped FAPs).
112
Ethology
113
Learning
Learning occurs in many ways, one of the most elementary being habituation.[11] This process consists of ignoring
persistent or useless stimuli. An example of learning by habituation is the one observed in squirrels: When one of
them feels threatened, the others hear its signal and go to the nearest refuge. However, if the signal comes from an
individual that has caused many false alarms, the other squirrels ignore the signal.
Another common way of learning is by association, where a stimulus is, based on the experience, linked to another
one that may not have anything to do with the first one. The first studies of associative learning were made by
Russian physiologist Ivan Pavlov.[12] An example of associative behaviour is observed when a common goldfish
goes close to the water surface whenever a human is going to feed it, or the excitement of a dog whenever it sees a
collar as a prelude for a walk.
Imprinting
Being able to discriminate the members of one's own species is
also of fundamental importance for reproductive success. Such
discrimination can be based on a number of factors. However, this
important type of learning only takes place in a very limited period
of time. This kind of learning is called imprinting,[13] and was a
second important finding of Lorenz. Lorenz observed that the
young of birds such as geese and chickens followed their mothers
spontaneously from almost the first day after they were hatched,
and he discovered that this response could be imitated by an
arbitrary stimulus if the eggs were incubated artificially and the
stimulus were presented during a critical period that continued for
a few days after hatching.
Example of imprinting in a moose
Imitation
Imitation is often an important type of learning. A well-documented example of imitative learning occurred in a
group of macaques on Hachijojima Island, Japan. The macaques lived in the inland forest until the 1960s, when a
group of researchers started giving them potatoes on the beach: soon, they started venturing onto the beach, picking
the potatoes from the sand, and cleaning and eating them.[14] About one year later, an individual was observed
bringing a potato to the sea, putting it into the water with one hand, and cleaning it with the other. Her behaviour was
soon imitated by the individuals living in contact with her; when they gave birth, they taught this practice to their
young.[15]
The National Institutes of Health reported that capuchin monkeys preferred the company of researchers who imitated
them to that of researchers who did not. The monkeys not only spent more time with their imitators but also
preferred to engage in a simple task with them even when provided with the option of performing the same task with
a non-imitator.[16]
Ethology
114
Mating and the fight for supremacy

Individual reproduction is the most important phase in the proliferation of individuals or genes within a species: for
this reason, there exist complex mating rituals, which can be very complex even if they are often regarded as fixed
action patterns (FAPs). The Stickleback's complex mating ritual was studied by Niko Tinbergen and is regarded as a
notable example of a FAP.
Often in social life, animals fight for the right to reproduce, as well as social supremacy. A common example of
fighting for social and sexual supremacy is the so-called pecking order among poultry. Every time a group of poultry
cohabitate for a certain time length, they establish a pecking order. In these groups, one chicken dominates the others
and can peck without being pecked. A second chicken can peck all the others except the first, and so on. Higher level
chickens are easily distinguished by their well-cured aspect, as opposed to lower level chickens. While the pecking
order is establishing, frequent and violent fights can happen, but once established, it is broken only when other
individuals enter the group, in which case the pecking order re-establishes from scratch.
Living in groups
Several animal species, including humans, tend to live in groups. Group size is a major aspect of their social
environment. Social life is probably a complex and effective survival strategy. It may be regarded as a sort of
symbiosis among individuals of the same species: a society is composed of a group of individuals belonging to the
same species living within well-defined rules on food management, role assignments and reciprocal dependence.
When biologists interested in evolution theory first started examining social behaviour, some apparently
unanswerable questions arose, such as how the birth of sterile castes, like in bees, could be explained through an
evolving mechanism that emphasizes the reproductive success of as many individuals as possible, or why, amongst
animals living in small groups like squirrels, an individual would risk its own life to save the rest of the group. These
behaviours may be examples of altruism.[17] Of course, not all behaviours are altruistic, as indicated by the table
below. For example, revengeful behaviour was at one point claimed to have been observed exclusively in Homo
sapiens. However, other species have been reported to be vengeful, including reports of vengeful camels[18] and
chimpanzees.[19]
Classification of social behaviours

Type of behaviour
Effect on the donor
Effect on the receiver
Egoistic
Increases fitness
Decreases fitness
Cooperative
Increases fitness
Increases fitness
Altruistic
Decreases fitness
Increases fitness
Revengeful
Decreases fitness
Decreases fitness
The existence of egoism through natural selection does not pose any question to evolution theory and is, on the
contrary, fully predicted by it, as is cooperative behaviour. It is more difficult to understand the mechanism through
which altruistic behaviour initially developed.
Ethology
Tinbergen's four questions for ethologists

Lorenz's collaborator, Niko Tinbergen, argued that ethology always needed to include four kinds of explanation in
any instance of behaviour:
Function How does the behaviour affect the animal's chances of survival and reproduction? Why does the
animal respond that way instead of some other way?
Causation What are the stimuli that elicit the response, and how has it been modified by recent learning?
Development How does the behaviour change with age, and what early experiences are necessary for the
animal to display the behaviour?
Evolutionary history How does the behaviour compare with similar behaviour in related species, and how
might it have begun through the process of phylogeny?
These explanations are complementary rather than mutually exclusiveall instances of behaviour require an
explanation at each of these four levels. For example, the function of eating is to acquire nutrients (which ultimately
aids survival and reproduction), but the immediate cause of eating is hunger (causation). Hunger and eating are
evolutionarily ancient and are found in many species (evolutionary history), and develop early within an organism's
lifespan (development). It is easy to confuse such questionsfor example, to argue that people eat because they're
hungry and not to acquire nutrientswithout realizing that the reason people experience hunger is because it causes
them to acquire nutrients.[20]
Growth of the field

Due to the work of Lorenz and Tinbergen, ethology developed strongly in continental Europe during the years prior
to World War II.[3] After the war, Tinbergen moved to the University of Oxford, and ethology became stronger in the
UK, with the additional influence of William Thorpe, Robert Hinde, and Patrick Bateson at the Sub-department of
Animal Behaviour of the University of Cambridge, located in the village of Madingley.[21] In this period, too,
ethology began to develop strongly in North America.
Lorenz, Tinbergen, and von Frisch were jointly awarded the Nobel Prize in Physiology or Medicine in 1973 for their
work of developing ethology.[22]
Ethology is now a well-recognised scientific discipline, and has a number of journals covering developments in the
subject, such as the Ethology Journal. In 1972, the International Society for Human Ethology was founded to
promote exchange of knowledge and opinions concerning human behavior gained by applying ethological principles
and methods and published their journal, The Human Ethology Bulletin. In 2008, in a paper published in the journal
Behaviour, ethologist Peter Verbeek introduced the term "Peace Ethology" as a sub-discipline of Human Ethology
that is concerned with issues of human conflict, conflict resolution, reconciliation, war, peacemaking, and
peacekeeping behavior.[23]
Today, along with actual ethologists, many biologists, zoologists, primatologists, anthropologists, veterinarians, and
physicians study ethology and other related fields such as animal psychology, the study of animal social groups, and
animal cognition. Some research has begun to study atypical or disordered animal behavior. Most researchers in the
field have some sort of advanced degree and specialty and subspecialty training in the aforementioned fields.
115
Ethology
116
Social ethology and recent developments

In 1970, the English ethologist John H. Crook published an important paper in which he distinguished comparative
ethology from social ethology, and argued that much of the ethology that had existed so far was really comparative
ethologyexamining animals as individualswhereas, in the future, ethologists would need to concentrate on the
behaviour of social groups of animals and the social structure within them.
Also in 1970, Robert Ardrey's book The Social Contract: A Personal Inquiry into the Evolutionary Sources of Order
and Disorder was published.[24] The book and study investigated animal behaviour and then compared human
behaviour to it as a similar phenomenon.
E. O. Wilson's book Sociobiology: The New Synthesis appeared in 1975, and since that time, the study of behaviour
has been much more concerned with social aspects. It has also been driven by the stronger, but more sophisticated,
Darwinism associated with Wilson, Robert Trivers, and William Hamilton. The related development of behavioural
ecology has also helped transform ethology. Furthermore, a substantial rapprochement with comparative psychology
has occurred, so the modern scientific study of behaviour offers a more or less seamless spectrum of approaches:
from animal cognition to more traditional comparative psychology, ethology, sociobiology, and behavioural ecology.
Sociobiology has more recently developed into evolutionary psychology.
List of ethologists
People who have made notable contributions to ethology (many are comparative psychologists):
Robert Ardrey
Judith Hand
Desmond Morris
John C Angel
Clarence Ellis Harbison
Martin Moynihan
Adrian Simpson
Heini Hediger
Caitlin O'Connell-Rodwell
Patrick Bateson
Oskar Heinroth
Manny Puig
John Bowlby
Robert Hinde
Irene Pepperberg
Donald Broom
Bernard Hollander
George Romanes
Marian Stamp Dawkins
Sarah Hrdy
Thomas A. Sebeok
Richard Dawkins
Julian Huxley
B. F. Skinner
Irenus Eibl-Eibesfeldt
Lynne Isbell
Barbara Smuts
John Endler
Julian Jaynes
William Homan Thorpe
Jean-Henri Fabre
Erich Klinghammer
Niko Tinbergen
Dian Fossey
John Krebs
Jakob von Uexkll
Karl von Frisch
Konrad Lorenz
Frans de Waal
Douglas P. Fry
Aubrey Manning
William Morton Wheeler
Jane Goodall
Eugene Marais
E. O. Wilson
James L. Gould
Patricia McConnell
Amotz Zahavi
[26]
[25]
References
[1] Nobel Prize page (http:/ / nobelprize. org/ nobel_prizes/ medicine/ laureates/ 1973/ index. html) for 1973 Medicine Award to Tinbergen,
Lorenz, and von Frisch for contributions in ethology
[2] Janes, Sharyn; Karen Saucier Lundy (2009). Community health nursing: caring for the public's health. Jones & Bartlett Learning. p.251.
ISBN9780763717865.
[3] Matthews, Janice R. (2009). Insect Behaviour. Springer. p.13. ISBN9789048123889.
[4] Bourg, Julian (2007). From revolution to ethics: May 1968 and contemporary French thought. McGill-Queen's Press - MQUP. p.155.
ISBN9780773531994.
[5] Buchmann, Stephen (2006). Letters from the Hive: An Intimate History of Bees, Honey, and Humankind. Random House of Canada. p.105.
ISBN9780553382662.
[6] Hallberg, Leif (2008). Walking the Way of the Horse: Exploring the Power of the Horse-Human Relationship. iUniverse. p.113.
ISBN9780595479085.
Ethology
[7] Bernstein, W M (2011). A Basic Theory of Neuropsychoanalysis. Karnac Books. p.81. ISBN9781855758094.
[8] Tinbergen, Niko 1953 The Herring Gull's World - London, Collins
[9] Tinbergen, N. (1951) The Study of Instinct. Oxford University Press, New York.
[10] "Barrett, Deirdre. Supernormal Stimuli: How Primal Urges Overran Their Evolutionary Purpose. NY NY: W.W. Norton, 2010" (http:/ /
www. amazon. com/ s?url=search-alias=stripbooks& field-keywords=supernormal+ stimuli& sprefix=supernorm). Amazon.com. . Retrieved
2011-11-08.
[11] Keil, Frank C.; Robert Andrew Wilson (2001). The MIT encyclopedia of the cognitive sciences. MIT Press. p.184. ISBN9780262731447.
[12] Hudmon, Andrew (2005). Learning and memory. Infobase Publishing. p.35. ISBN9780791086384.
[13] Mercer, Jean (2006). Understanding attachment: parenting, child care, and emotional development. Greenwood Publishing Group. p.19.
ISBN9780275982171.
[14] Wilson, Edward O. (2000). Sociobiology: the new synthesis. Harvard University Press. p.170. ISBN9780674000896.
[15] "Japanese Macaque - Macaca fuscata" (http:/ / www. blueplanetbiomes. org/ japanese_macaque. htm). Blueplanetbiomes.org. . Retrieved
2011-11-08.
[16] "Imitation Promotes Social Bonding in Primates, August 13, 2009 News Release - National Institutes of Health (NIH)" (http:/ / www. nih.
gov/ news/ health/ aug2009/ nichd-13. htm). Nih.gov. 2009-08-13. . Retrieved 2011-11-08.
[17] Cummings, Mark; Carolyn Zahn-Waxler and Ronald Iannotti (1991). Altruism and aggression: biological and social origins. Cambridge
University Press. p.7. ISBN9780521423670.
[18] "The Ape and the Sushi Master" (http:/ / books. google. com/ books?id=eJFlGdPEBfYC& printsec=frontcover#PPA338,M1).
Books.google.com. . Retrieved 2011-11-08.
[19] "Beyond Revenge" (http:/ / books. google. com/ books?id=daomTGYZuW4C& printsec=frontcover#PPA79,M1). Books.google.com. .
[20] Barrett et al. (2002) Human Evolutionary Psychology. Princeton University Press.
[21] Bateson, Paul Patrick Gordon (1991). The Development and integration of behaviour: essays in honour of Robert Hinde. Cambridge
University Press. p.479. ISBN9780521407090.
[22] Encyclopaedia Britannica (1975). Yearbook of science and the future. p.248.
[23] Verbeek, Peter. (2008) "Peace Ethology." Behaviour 145, 1497-1524
[24] Ardrey, Robert (1970). The Social Contract: A Personal Inquiry into the Evolutionary Sources of Order and Disorder. Atheneum.
[25] http:/ / www. anthro. ucla. edu/ becCaitlin/
[26] http:/ / www. anthro. ucdavis. edu/ lynneisbell/ index. html
Further reading
Klein, Z. (2000). "The ethological approach to the study of human behavior" (http://www.nel.edu/21_6/
NEL21062000X001_Klein_.pdf). Neuroendocrinology Letters (21): 477481.
Karen Shanor and Jagmeet Kanwal: Bats Sing, Mice Giggle: Revealing the Secret Lives of Animals, Icon (2009).
'Accessible to the lay reader and acceptable to the scientific community' (The Daily Telegraph), 10 October 2009.
External links
Konrad Lorenz Institute for Evolution and Cognitive Research (http://www.kli.ac.at/)

Center for the Integrative Study of Animal behaviour (http://www.indiana.edu/~animal/)
Introduction to ethology (http://cas.bellarmine.edu/tietjen/Ethology/introduction_to_ethology.htm)
Applied Ethology (http://www.usask.ca/wcvm/herdmed/applied-ethology/)
The International Society for Human Ethology (http://evolution.anthro.univie.ac.at/ishe/) aims at
promoting ethological perspectives in the scientific study of humans worldwide
Abstracts of the XXIX Ethological Conference (http://www.behav.org/IEC/default.php/)
Center for Avian Cognition (http://digitalcommons.unl.edu/biosciaviancog/) University of Nebraska (Alan
Kamil, Alan Bond)
Diagrams on Tinbergen's four questions
The Four Areas of Biology (http://www-personal.umich.edu/~nesse/fourquestions.pdf)
The Four Areas of Biology AND levels of inquiry (http://homepage.uibk.ac.at/~c720126/humanethologie/
ws/medicus/block1/4BQ_E.pdf)
117
Adoption home study
Adoption home study

A home study or homestudy is a screening of the home and life of prospective adoptive parents prior to allowing an
adoption to take place. In some places, and in all international adoptions, a home study is required by law.[1] [2] Even
where it is not legally mandated, it may be required by an adoption agency. Depending on the location and agency,
different information may be sought during a home study.
A home study can be used both to aid the prospective parents in preparing to raise an adoptive child, and to rule out
those who are not fit to be parents.[3]
The ultimate purpose of a home study is for the benefit of the child, not the parents. Therefore, screeners are
instructed to be thorough in their examinations.[4]
There is typically a cost to a home study, which is usually several hundred to several thousand US dollars. In most
cases, the prospective adoptive parents are responsible to cover the cost.
Information
The types of information that may be sought from a home study include the determination if there is abuse in the
past, family background, employment history, a criminal background check of the prospective parents, a credit
check, medical records, and an examination of the home.[5] [6]
A home study, as its name implies, examines the dwelling of the prospective parents. Factors that may be taken into
account include the cleanliness and condition of the home, fire safety, sanitation, and the well-being of the
neighborhood where the home is located.
Factors pertaining to the people may include their desire to adopt, their understanding of the relationship between
adoptive parents and children, and their willingness to share with an adopted child the fact that they are adopted.
Criticism of home studies

Home studies are criticized by many who feel they are intrusive, or who feel that there may be discrimination against
certain people who are perfectly capable of parenting, but are ruled out due to various issues.
References
[1] http:/ / books. google. com/ books?id=PGuRz2i5y1sC& pg=PA144& dq=%22home+ study%22adoption& lr=& as_brr=3& ie=ISO-8859-1&
output=html
[2] http:/ / home-study. adoption. com/
[3] http:/ / books. google. com/ books?id=uJnRIt_XsjsC& pg=PA54& dq=%22home+ study%22adoption& as_brr=3& ie=ISO-8859-1&
output=html
[4] http:/ / books. google. com/ books?id=p7ReHKEYbiMC& pg=PA20& vq=%22home+ study%22& dq=%22home+ study%22adoption&
as_brr=3& ie=ISO-8859-1& output=html& source=gbs_search_s& cad=0
[5] http:/ / books. google. com/ books?id=rIA0BAyVLTgC& pg=PA20& vq=%22home+ study%22& dq=%22home+ study%22adoption&
as_brr=3& ie=ISO-8859-1& output=html& source=gbs_search_s& cad=0
[6] http:/ / adoption. about. com/ od/ adopting/ a/ homestudy. htm
118
Child protection
Child protection
Child protection is used to describe a set of usually government-run services designed to protect children and young
people who are underage and to encourage family stability. These typically include foster care, adoption services,
services aimed at supporting at-risk families so they can remain intact, and investigation of alleged child abuse.
Most children who come to the attention of the child welfare system do so because of any of the following situations,
which are often collectively termed child abuse:
Child sexual abuse
Neglect including the failure to take adequate measures to safeguard a child from harm and/or gross negligence in
providing for a child's basic needs:
Physical abuse
Psychological abuse
The United States government's Administration for Children and Families reported that in 2004 approximately 3.5
million children were involved in investigations of alleged abuse or neglect in the US, while an estimated 872,000
children were determined to have been abused or neglected and an estimated 1,490 children died that year because of
abuse or neglect. In 2007, 1,760 children died as the result of child abuse and neglect.[1] Child abuse impacts the
most vulnerable populations with children under age five years accounting for 76% of fatalities.[2] In 2008, 8.3
children per 1000 were victims of child abuse and neglect and 10.2 children per 1000 were in out of home
placement.[3]
History
The concept of a state sanctioned child welfare system dates back to Plato's Republic. Plato theorised that the
interests of the child could be served by removing children from the care of their parents and placing them into state
custody. To prevent an uprising from dispossessed parents: "We shall have to invent some ingenious kind of lots
which the less worthy may draw on each occasion of our bringing them together, and then they will accuse their own
ill-luck and not the rulers."[4]
Provincial or state governments child protection legislation which empowers the government department or agency
to provide services in the area and to intervene into families where child abuse or other problems are suspected. The
agency that manages these services has various names in different provinces and states, e.g., department of children's
services, children's aid, department of child and family services. There is some consistency in the nature of laws,
though the application of the laws varies across the country.
The United Nations has addressed child abuse as a human rights issue, adding a section specifically to children in the
Universal Declaration of Human Rights:
Recognizing that the child, for the full and harmonious development of his or her personality, should grow up in a
family environment, in an atmosphere of happiness, love and understanding should be afforded the right to
survival; to develop to the fullest; to protection from harmful influences, abuse and exploitation; and to participate
fully in family, cultural and social life.
119
Child protection
U.S. History
In 1853, the Children's Aid Society[5] was founded in response to the problem of orphaned or abandoned children
living in New York. Rather than allow these children to become institutionalized or continue to live on the streets,
the children were placed in the first foster homes, but typically with the intention of helping these families work
their farms.[6] [7]
In 1874, the first case of child abuse was criminally prosecuted in what has come to be known as the case of Mary
Ellen. Outrage over this case started an organized effort against child maltreatment [8] In 1909, President Roosevelt
convened the White House Conference on Child Dependency, which created a publicly funded volunteer
organization to establish and publicize standards of child care.[6] By 1926, 18 states had some version of county
child welfare boards whose purpose was to coordinate public and private child related work.[7] Issues of abuse and
neglect were addressed in the Social Security Act in 1930, which provided funding for intervention for neglected
and dependent children in danger of becoming delinquent. [8]
In the 1940s and 1950s, due to improved technology in diagnostic radiology, the medical profession began to take
notice of what they believed to be intentional injuries.[9] In 1961, Dr. Kempe[10] began to further research this issue,
eventually coining the term battered child syndrome.[9] At this same time, there were also changing views about the
role of the child in society, fueled in part by the civil rights movement.[7]
In 1973, congress took the first steps toward enacting federal legislature to address the issue of child abuse. The
Child Abuse Prevention and Treatment Act[11] was passed in 1974, which required states to prevent, identify and
treat child abuse and neglect. [8]
Shortly thereafter, in 1978, the Indian Child Welfare Act (ICWA) was passed. This act was passed in response to
concerns that large numbers of Native American Children were being separated from their tribes and placed in foster
care.[12] This legislation not only opened the door for consideration of cultural issues while stressing ideas that
children should be with their families, leading to the beginnings of family preservation programs.[13]
In 1980, the Adoption Assistance Act[14] was introduced as a way to manage the high numbers of children in
placement.[7] Although this legislation addressed some of the complaints from earlier pieces of legislation around
ensuring due process for parents, these changes did not alleviate the high numbers of children in placement or
continuing delays in permanence.[13] This led to the introduction of the home visitation models, which provided
funding to private agencies to provide intensive family preservation services.[7]
In addition to family preservation services, the focus of federal child welfare policy changed to try to address
permanence for the large numbers of foster children care.[13] Several pieces of federal legislation attempted to ease
the process of adoption including Adoption Assistance Act,[15] 1988 Child Abuse and Prevention and Adoption and
Family Services Act, 1992 Child Abuse, Domestic Violence and Adoption and Family Services Act [16] . The 1994
Multi Ethnic Placement Act, which was revised in 1996 to add the Interethnic Placement Provisions, also attempted
to promote permanency through adoption, creating regulations that adoptions could not be delayed or denied due to
issues of race, color or national origin of the child or the adoptive parent.[17]
All of these policies led up to the 1997 Adoption and Safe Families Act(ASFA), much of which guides current
practice. Changes in the Adoptions and Safe Families Act showed a interest in both protecting childrens safety and
developing permanency.[17] This law requires counties to provide reasonable efforts (treatment) to preserve or
reunify families, but also shortened time lines required for permanence, leading to termination of parental rights
should these efforts fail.[7] [17] ASFA introduced the idea of concurrent planning which demonstrated attempts to
reunify families as the first plan, but to have a back-up plan so as not to delay permanency for children (Michell, et
al. 2005).
120
Child protection
Worldwide
United Kingdom
The United Kingdom has a comprehensive child welfare system under which Local Authorities have duties and
responsibilities towards children in need in their area. This covers provision of advice and services, accommodation
and care of children who become uncared for, and also the capacity to initiate proceedings for the removal of
children from their parents care/care proceedings. The criteria for the latter is 'significant harm' which covers
physical, sexual and emotional abuse and neglect. In appropriate cases the Care Plan before the Court will be for
adoption. The Local Authorities also run adoption services both for children put up for adoption voluntarily and
those becoming available for adoption through Court proceedings. The basic legal principle in all public and private
proceedings concerning children, under the Children Act 1989, is that the welfare of the child is paramount. In
recognition of attachment issues, social work good practice requires a minimal number of moves and the 1989
Children Act enshrines the principle that delay is inimical to a child's welfare. Care proceedings have a time frame of
40 weeks and concurrent planning is required. The final Care Plan put forward by the Local Authority is required to
provide a plan for permanence, whether with parents, family members, long-term foster parents or adopters.
Nevertheless, 'drift' and multiple placements still occur as many older children are difficult to place or maintain in
placements. The role of Independent Visitor, a voluntary post, was created in the United Kingdom under the 1989
Children Act to befriend and assist children and young people in care.
In England, Wales and Scotland, there never has been a statutory obligation to report alleged child abuse to the
Police. However both the Children Act 1989 and 2004 makes clear a statutory obligation on all professionals to
report suspected child abuse.
The statutory guidance Working Together to Safeguard Children 2006 created the role of Local Authority
Designated Officer, "LADO". This officer is responsible for managing allegations of abuse against adults who work
with children (Teachers, Social Workers,Church leaders, Youth Workers etc.).
Local Safeguarding Children Boards (LSCB's) are responsible ensuring agencies and professionals,in their
area,effectivley safeguard and promote the welfare of children. In the event of the death or serious injury of a child,
LSCB's can initiate a 'Serious Case Review' aimed at identifying agency failings and improving future practice.
The planned ContactPoint database, under which information on children is shared between professionals, has been
halted by the newly elected coalition government (May 2010). The database was aimed at improving information
sharing across agencies. Lack of information sharing had been identified as a failing in numerous high profile child
death cases. Critics of the scheme claimed it was evidence of a 'big brother state' and too expensive to introduce.
Working Together to Safeguard Children 2006 (updated in 2010) and the subsequent 'The Protection of Children in
England: A Progress Report' (Laming, 2009) continue to promote the sharing of data between those working with
vulnerable children.[18]
A child in suitable cases can be made a ward of court and no decisions about the child or changes in its life can be
made without the leave of the High Court.
In England the Murder of Victoria Climbi was largely responsible for various changes in child protection in
England, including the formation of the Every Child Matters programme in 2003. A similar programme - Getting it
Right for Every Child - GIRFEC was established in Scotland in 2008.
121
Child protection
Canada
In Ontario, services are provided by independent Children's Aid Societies.[19] The societies receive funding from,
and are under the supervision of the Ontario Ministry of Children and Youth Services.[20] However, they are
regarded as a Non-governmental organization (NGO) which allows the CAS a large degree of autonomy from
interference or direction in the day to day running of CAS by the Ministry. The Child and Family Services Review
Board exists to investigate complaints against CAS and maintains authority to act against the societies. [21]
Effects of early maltreatment on children in child welfare

Children with histories of maltreatment, such as physical and psychological neglect, physical abuse, and sexual
abuse, are at risk of developing psychiatric problems.[22] [23] Such children are at risk of developing a disorganized
attachment.[24] [25] [26] Disorganized attachment is associated with a number of developmental problems, including
dissociative symptoms,[27] as well as depressive, anxiety, and acting-out symptoms.[28] [29]
Ideology of Child Protection

When a case of child abuse is reported, an investigation begins. This can result in significantly different responses
from the affected family and the child protection service workers. The family experiences fear, anxiety, and the need
to cope with the situation, whereas the professional has to stick to procedures to avoid blame in case something goes
wrong. The best outcome for the child occurs if the congruence between professional and family perspectives is
high. Ideology associated with child protection involve distinct discourses, which are peoples communication
practices at an intersubjective level. These ideological discourses are blame, bureaucratic, medical, penal,
humanistic, and technocratic. The blame discourse involves people holding others, like the parent or social worker,
responsible in case something bad happens to the child. Here, the media might be used as a tool for moral crusades.
Bureaucratic procedures engage all the steps which an organization like Child Protection Service has undertake, e.g.
case conferences, reviews, registers, etc. Hereby, the purpose is to avoid criticism. From the medical perspective, the
offender is viewed as an individual with a medical history, syndromes, and pathology. The purpose is to treat and
cure the parent, with the aid of medical expertise and technology. The penal discourse implies the legal actions that
follow the act of depravity or abuse punishing the offender. Humanistic discourse encompasses sympathy or feelings
of pity that the Child Protection worker might have towards people who are responsible for the situation in which the
victim is in. The technocratic discourse involves risk assessment gadgets in order to solve the situation. Here, a
mechanical classification and processing of the client is thought to be useful.[30]
Criticism
Despite the benefits of the services of the CPS, in the last two decades, the CPS has come under intense private and
public scrutiny as an institution than can and has caused great harm in the name of protection. Although child
welfare agencies are generally viewed positively, there has been an increase in the amount of cases where critics
believe CPS have reacted out of their bounds.
A notable recent case is the family of Gary and Melissa Gates in Texas. The school called the local CPS and
requested the Child Protective Services forcibly remove all thirteen of the Gates children and take them to foster
homes under a court order which allowed an Emergency Removal, when there is clear evidence of danger to the
physical health & safety of the child. The local CPS gave the explanation that they felt, quote, "Mr. Gates was
uncooperative and his uncooperativeness with us put the children at risk." Even though the court ordered the children
to be returned, CPS continues to classify the Gates as child abusers. Some have accused the CPS of having too much
immediate power leaving the parents feeling lost and aggravated. The CPS has been accused of prejudging parents
before proper investigations were done.
122
Child protection
An ongoing case about Nastic family living in U.S. has received an intervention from the Serbia government.
Children were taken away from their parents after their naked photos were found on the father's computer. Such
photos are common in Serbia culture. Furthermore, parents claim that their ethnic and religious rights have been
violated - children are not permitted to speak Serbian, nor to meet with their parents for orthodox Christmas. They
can meet only mother once a week. Children have suffered psychological traumas due to their separation from
parents. Polygraph showed that father did not abuse children. Trial is set for January 26. Psychologists from Serbia
stated that few hours of conversation with children are enough to see whether they have been abused. Children were
taken from their family 7 months ago. FBI started an investigation against the CPS. [31] [32] [33]
Brenda Scott, in her study of CPS concluded, "Child Protective Services is out of control. The system, as it operates
today, should be scrapped. If children are to be protected in their homes and in the system, radical new guidelines
must be adopted. At the core of the problem is the anti-family mindset of CPS. Removal is the first resort, not the
last. With insufficient checks and balances, the system that was designed to protect children has become the greatest
perpetrator of harm."[34] Further to that information, several former CPS workers retired from the service, due to
increasing circumstances and practices carried out by the organization.
Texas 2008 Raid of YFZ Ranch

In April 2008, the largest child protection action in American history raised questions as the CPS in Texas removed
hundreds of minor children, infants, and women incorrectly believed to be children from the YFZ Ranch polygamist
community, with the assistance of heavily armed police with an armored personnel carrier. Investigators, including
supervisor Angie Voss convinced a judge that all of the children were at risk of child abuse because they were all
being groomed for under-age marriage. The state supreme court disagreed, releasing most children back to their
families. Investigations would result in criminal charges against some men in the community.
Gene Grounds of Victim Relief Ministries commended CPS workers in the Texas operation as exhibiting
compassion, professionalism and caring concern.[35] However, CPS performance was questioned by workers from
the Hill Country Community Mental Health-Mental Retardation Center. One wrote "I have never seen women and
children treated this poorly, not to mention their civil rights being disregarded in this manner" after assisting at the
emergency shelter. Others who were previously forbidden to discuss conditions working with CPS later produced
unsigned written reports expressed anger at the CPS traumatizing the children, and disregarding rights of mothers
who appeared to be good parents of healthy, well-behaved children. CPS threatened some MHMR workers with
arrest, and the entire mental health support was dismissed the second week due to being "too compassionate."
Workers believed poor sanitary conditions at the shelter allowed respiratory infections and chicken pox to spread.[36]
CPS problem reports

The Texas Department of Family and Protective Services, as with other states, had itself been an object of reports of
unusual numbers of poisonings, death, rapes and pregnancies of children under its care since 2004. The Texas
Family and Protective Services Crisis Management Team was created by executive order after the critical report
Forgotten Children[37] of 2004. Texas Comptroller Carole Keeton Strayhorn made a statement in 2006 about the
Texas foster care system.[38] In Fiscal 2003, 2004 and 2005, respectively 30, 38 and 48 foster children died in the
state's care. The number of foster children in the state's care increased 24 percent to 32,474 in Fiscal 2005, while the
number of deaths increased 60 percent. Compared to the general population, a child is four times more likely to die
in the Texas foster care system. In 2004, about 100 children were treated for poisoning from medications; 63 were
treated for rape that occurred while under state care including four-year old twin boys, and 142 children gave birth,
though others believe Ms. Strayhorn's report was not scientifically researched, and that major reforms need to be put
in place to assure that children in the conservatorship of the state get as much attention as those at risk in their
homes.
123
Child protection
Responsibility for misconduct

In May 2007, the United States 9th Circuit Court of Appeals found in ROGERS v. COUNTY OF SAN JOAQUIN,
No. 05-16071[39] that a CPS social worker acting without due process and without exigency (emergency conditions)
violated the 14th Amendment and Title 42 United State Code Section 1983. The Fourteenth Amendment to the
United States Constitution says that a state may not make a law that abridges "abridge the privileges or immunities of
citizens of the United States" and no state may "deprive any person of life, liberty, or property, without due process
of law; nor deny to any person within its jurisdiction the equal protection of the laws." Title 42 United States Code
Section 1983[40] states that citizens can sue a person that deprives them of their rights under the pretext of a
regulation of a state.
Disproportionality & Disparity in the Child Welfare System

In the United States, data suggests that a disproportionate number of minority children, particularly African
American and Native American children, enter the foster care system.[41] National data in the United States provides
evidence that disproportionality may vary throughout the course of a child's involvement with the child welfare
system. Differing rates of disproportionality are seen at key decision points including the reporting of abuse,
substantiation of abuse, and placement into foster care.[42] Additionally, once they enter foster care, research
suggests that they are likely to remain in care longer.[43] Research has shown that there is no difference in the rate of
abuse and neglect among minority populations when compared to Caucasian children that would account for the
disparity.[44] The Juvenile Justice system has also been challenged by disproportionate negative contact of minority
children.[45] Because of the overlap in these systems, it is likely that this phenomenon within multiple systems may
be related.
References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
Preventchildabuseny.org (http:/ / preventchildabuseny. org/ pdf/ 2007CANFactSheet. pdf)

Americanhumane.org (http:/ / www. americanhumane. org/ about-us/ newsroom/ fact-sheets/ fatalities-due-to-child-abuse-neglect. html)
Kidscount.org (http:/ / datacenter. kidscount. org/ )
MDX.ac.uk (http:/ / www. mdx. ac. uk/ WWW/ STUDY/ xpla5. htm)
Childrensaidsociety.org (http:/ / www. childrensaidsociety. org/ about/ history)
Axin, J & Levin, H (1997) Social Welfare; A history of the American Response to Need 4th ed. White Plains, NY: Longman.
Ellett, A. J., & Leighninger, L. (2007). What happened? An historical perspective of the deprofessionalization of child welfare practice with
implications for policy and practice. Journal of Public Child Welfare, 1(1), 3-24.
[8] Crosson-Tower, C. (1999). Understanding Child Abuse and Neglect. 4th Ed. Boston: Allyn& Bacon.
[9] Antler, S. (1978) Child Abuse: An emerging social priority. Social Work, 23, 58-61
[10] Kempe.org (http:/ / www. kempe. org/ )
[11] Childwelfare.gov (http:/ / www. childwelfare. gov/ systemwide/ laws_policies/ federal/ index. cfm?event=federalLegislation. viewLegis&
id=2)
[12] Limb, G. E., & Chance, T. (2004). An empirical examination of the Indian child welfare act and its impact on cultural and familial
preservation for American Indian children. Child Abuse and Neglect, 28(12), 1279-1289
[13] Mitchell, L.B., Barth, R.P., Green, R., Wall, A., Biemer, P., Berrick, J. D., & Webb, M. B. (2005). Child welfare reform in the United States:
Findings form a local agency survey. Child Welfare, 84(1), 5-24
[14] Childwelfare.gov (http:/ / www. childwelfare. gov/ systemwide/ laws_policies/ federal/ index. cfm?event=federalLegislation. viewLegis&
id=22)
[15] 1980 Childwelfare.gov (http:/ / www. childwelfare. gov/ pubs/ otherpubs/ majorfedlegis. cfm)
[16] http:/ / www. childwelfare. gov/ pubs/ otherpubs/ majorfedlegis. cfm
[17] Lincroft, Y., & Resher, J. (2006). Undercounted and underserved: Immigrant and refugee families in the child welfare system. Report to the
Annie E. Casey Foundation: Balitmore, MD
[18] DCSF.gov.uk (http:/ / www. dcsf. gov. uk/ everychildmatters/ strategy/ deliveringservices1/ informationsharing/ informationsharing/ )
[19] "About Ontario's children's aid societies" (http:/ / www. children. gov. on. ca/ htdocs/ English/ topics/ childrensaid/ childrensaidsocieties/
index. aspx). Ontario Ministry of Children and Youth Services. . Retrieved 19 April 2011.
[20] http:/ / www. e-laws. gov. on. ca/ html/ statutes/ english/ elaws_statutes_90c11_e. htm#BK10
[21] "Complaints Against a Children's Aid Society" (http:/ / www. cfsrb. ca/ en/ cfsrb/ about/ history). Child and Family Services Review Board.
. Retrieved 17 April 2011.
124
Child protection
[23] Malinosky-Rummell, R. & Hansen, D.J. (1993) Long term consequences of childhood physical abuse. Psychological Bulletin 114, 68-69
attentional strategies. In J. Cassidy & P. Shaver (Eds.) Handbook of Attachment. (pp. 520-554). NY: Guilford Press
[25] Solomon, J. & George, C. (Eds.) (1999). Attachment Disorganization. NY: Guilford Press
[26] Main, M. & Hesse, E. (1990) Parents Unresolved Traumatic Experiences are related to infant disorganized attachment status. In M. T.
Greenberg, D. Ciccehetti, & E. M. Cummings (Eds), Attachment in the Preschool Years: Theory, Research, and Intervention (pp161-184).
[27] Carlson, E. A. (1988). A prospective longitudinal study of disorganized/disoriented attachment. Child Development 69, 1107-1128
[28] Lyons-Ruth, K. (1996). Attachment relationships among children with aggressive behavior problems: The role of disorganized early
attachment patterns. Journal of Consulting and Clinical Psychology 64, 64-73
[29] Lyons-Ruth, K., Alpern, L., & Repacholi, B. (1993). Disorganized infant attachment classification and maternal psychosocial problems as
predictors of hostile-aggressive behavior in the preschool classroom. Child Development 64, 572-585
[30] Sinclair, T. (2005). Mad, bad or sad? Ideology, distorted communication and child abuse prevention. The Australian Sociological
Association, 41, 227-246.
[31] http:/ / globalvoicesonline. org/ 2011/ 01/ 04/ united-states-serbian-couple-struggles-to-get-children-back/
[32] http:/ / www. b92. net/ eng/ news/ society-article. php?yyyy=2010& mm=12& dd=21& nav_id=71657
[33] http:/ / www. pressonline. rs/ sr/ vesti/ u_fokusu/ story/ 146886/ Otac+ na+ poligrafu+ dokazao+ da+ nije+ zlostavljao+ decu. html
[34] Scott, Brenda (1994) Out of Control. Who's Watching Our Child Protection Agencies? p. 179
[35] KVUE.com (http:/ / www. kvue. com/ news/ state/ stories/ 041808kvuejanetpolygamy-cb. 779df065. html), Richardson group: Polygamists'
children are OK April 18, 2008 by Janet St. James / WFAA-TV
[36] Crotea, Roger (10 May 2008). "Mental health workers rip CPS over sect" (http:/ / www. chron. com/ disp/ story. mpl/ headline/ metro/
5770183. html). San Antonio Express-news . .
[37] Window.state.tx.us (http:/ / www. window. state. tx. us/ forgottenchildren/ in)
[38] Comptroller Strayhorn Statement On Foster Care Abuse June 23, 2006 (http:/ / www. window. state. tx. us/ news/ 60623statement. html)
[39] UScourts.gov (http:/ / www. ca9. uscourts. gov/ ca9/ newopinions. nsf/ 2DA8C6954EA9C8A3882572EA00532815/ $file/ 0516071.
pdf?openelement)
[40] Cornell.edu (http:/ / www. law. cornell. edu/ uscode/ 42/ usc_sec_42_00001983----000-. html)
[41] Hill R.B. (2004) Institutional racism in child welfare. In J. Everett, S. Chipungu & B. Leashore (Eds.) Child welfare revisited (pp. 57-76).
New Brunswick, NJ: Rutgers University Press.
[42] Hill, R. B (2006) Synthesis of research on disproportionality in child welfare: An update. Casey-CSSP Alliance for Racial Equity in Child
Welfare.
[43] Wulczyn, F. Lery, B., Haight, J., (2006) Entry and Exit Disparities in the Tennessee Foster Care System. Chapin Hall Discussion Paper.
[44] National Incidence Study (NIS), U.S. Department of Health & Human Services, Administration for Children & Families, (1996)
[45] Pope, C.E. & Feyerherm, W. (1995) Minorities and the Juvenile Justice System Research Symmary. Washington, DC: Office of Juvenile
Justice and Delinquency Prevention
External links
NCCPR Website (http://nccpr.info/) NCCPR provides reports and information on how (US) child protection
systems are performing and how to make them perform better for children.
"CCPAS Website" (http://www.ccpas.co.uk) The Churches Child Protection Advisory Service (CCPAS) - the
only independent Christian charity providing professional advice, CRB checks, support, training and resources in
all areas of safeguarding children and for those affected by abuse.
Resist.ca (http://users.resist.ca/~kirstena/machallinstitutionhistory.html) (History of Child Protection in
America by Kirsten Anderberg, Graduate History Student, 2009)
HHS.gov (http://www.acf.hhs.gov/programs/cb/pubs/cm04) (accessed 8/4/06)
HHS.com (http://www.acf.hhs.gov/programs/cb/stats_research/afcars/tar/report11.htm) (accessed 8/4/06)
Childwelfare.org (http://www.childwelfare.gov/) (accessed 10/19/06)
Wikichild.org (http://www.wikiprogress.org/index.php/Child_well-being) (accessed 21/07/11)
A Report Card on Child Protection (http://www.unicef.org/protection/files/Progress_for_Children-No.
8_EN_081309(1).pdf). (PDF-File, 991KB) United Nations Childrens Fund: Progress for Children, Number
8. September 2009.
125
Child protection
Further reading
McCutcheon, James, 2010."Historical Analysis and Contemporary Assessment of Foster Care in Texas:
Perceptions of Social Workers in a Private, Non-Profit Foster Care Agency". Applied Research Projects. Texas
State University Paper 332. TXstate.edu (http://ecommons.txstate.edu/arp/332)
Handbook: Child protection (http://www.ipu.org/PDF/publications/childprotection_en.pdf) UNICEF, IPU,
2004
Child abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child.[1] In the United States, the Centers
for Disease Control and Prevention (CDC) and the Department of Children And Families (DCF) define child
maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in
harm, potential for harm, or threat of harm to a child.[2] Child abuse can occur in a child's home, or in the
organizations, schools or communities the child interacts with. There are four major categories of child abuse:
neglect, physical abuse, psychological/emotional abuse, and child sexual abuse.
Different jurisdictions have developed their own definitions of what constitutes child abuse for the purposes of
removing a child from his/her family and/or prosecuting a criminal charge. According to the Journal of Child Abuse
and Neglect, child abuse is "any recent act or failure to act on the part of a parent or caretaker which results in death,
serious physical or emotional harm, sexual abuse or exploitation, an act or failure to act which presents an imminent
risk of serious harm".[3] A person who feels the need to abuse or neglect a child may be described as a "pedopath".[4]
Types
Child abuse can take several forms:[5] The four main types are physical, sexual, psychological, and neglect.[6]
Neglect
Child neglect is where the responsible adult does not provide adequately for various needs, including physical (not
providing adequate food, clothing, or hygiene), emotional (not providing nurturing or affection), educational (not
providing an adequate education), or medical (not medicating the child or taking him or her to the doctor). There are
many effects of child neglect, such as children not being able to interact with other children around them.[7] The
continuous refusal of a child's basic needs is considered chronic neglect.[8]
Physical abuse
Physical abuse is physical aggression directed at a child by an adult. It can involve punching, striking, kicking,
shoving, slapping, burning, bruising, pulling ears or hair, stabbing, choking, belting or shaking a child. Shaking a
child can cause shaken baby syndrome, which can lead to intracranial pressure, swelling of the brain, diffuse axonal
injury, and oxygen deprivation; which leads to patterns such as failure to thrive, vomiting, lethargy, seizures, bulging
or tense fontanels, altered breathing, and dilated pupils. The transmission of toxins to a child through its mother
(such as with fetal alcohol syndrome) can also be considered physical abuse in some jurisdictions.
Most nations with child-abuse laws consider the infliction of physical injuries or actions that place the child in
obvious risk of serious injury or death to be illegal. Beyond this, there is considerable variation. The distinction
between child discipline and abuse is often poorly defined. Cultural norms about what constitutes abuse vary widely:
among professionals as well as the wider public, people do not agree on what behaviors constitute abuse.[9]
Some human-service professionals claim that cultural norms that sanction physical punishment are one of the causes
of child abuse, and have undertaken campaigns to redefine such norms.[10]
126
Child abuse
Child sexual abuse

Child sexual abuse (CSA) is a form of child abuse in which an adult or older adolescent abuses a child for sexual
stimulation.[11] [12] Forms of CSA include asking or pressuring a child to engage in sexual activities (regardless of
the outcome), indecent exposure of the genitals to a child, displaying pornography to a child, actual sexual contact
against a child, physical contact with the child's genitals, viewing of the child's genitalia without physical contact, or
using a child to produce child pornography.[11] [13] [14] Selling the sexual services of children may be viewed and
treated as child abuse with services offered to the child rather than simple incarceration.[15]
Effects of child sexual abuse include guilt and self-blame, flashbacks, nightmares, insomnia, fear of things associated
with the abuse (including objects, smells, places, doctor's visits, etc.), self-esteem issues, sexual dysfunction, chronic
pain, addiction, self-injury, suicidal ideation, somatic complaints, depression,[16] post-traumatic stress disorder,[17]
anxiety,[18] other mental illnesses (including borderline personality disorder[19] and dissociative identity disorder,[19]
propensity to re-victimization in adulthood,[20] bulimia nervosa,[21] physical injury to the child, among other
problems.[22] Approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were
children.[23] [24] [25] [26] [27] Most sexual abuse offenders are acquainted with their victims; approximately 30% are
relatives of the child, most often brothers, fathers, mothers, uncles or cousins; around 60% are other acquaintances
such as friends of the family, babysitters, or neighbours; strangers are the offenders in approximately 10% of child
sexual abuse cases.[23]
Psychological/emotional abuse
Out of all the possible forms of abuse, emotional abuse is the hardest to define. It could include name-calling,
ridicule, degradation, destruction of personal belongings, torture or destruction of a pet, excessive criticism,
inappropriate or excessive demands, withholding communication, and routine labeling or humiliation.[28]
Victims of emotional abuse may react by distancing themselves from the abuser, internalizing the abusive words, or
fighting back by insulting the abuser. Emotional abuse can result in abnormal or disrupted attachment development,
a tendency for victims to blame themselves (self-blame) for the abuse, learned helplessness, and overly passive
behavior.[28]
Prevalence
According to the (American) National Committee to Prevent Child Abuse, in 1997 neglect represented 54% of
confirmed cases of child abuse, physical abuse 22%, sexual abuse 8%, emotional maltreatment 4%, and other forms
of maltreatment 12%.[29]
A UNICEF report on child wellbeing[30] stated that the United States and the United Kingdom ranked lowest among
industrial nations with respect to the wellbeing of children. It also found that child neglect and child abuse were far
more common in single-parent families than in families where both parents are present.
In the USA, neglect is defined as the failure to meet the basic needs of children including housing, clothing, food and
access to medical care. Researchers found over 91,000 cases of neglect in one year (from October 2005 to 30
September 2006) using information from a database of cases verified by protective services agencies.[2]
Neglect could also take the form of financial abuse by not buying the child adequate materials for survival.[31]
The U.S. Department of Health and Human Services reports that for each year between 2000 and 2005, "female
parents acting alone" were most likely to be perpetrators of child abuse.[32]
127
Child abuse
Fatalities
A child abuse fatality: when a childs death is the result of abuse or neglect, or when abuse and/or neglect are
contributing factors to a childs death. In the United States, 1,730 children died in 2008 due to factors related to
abuse; this is a rate of 2.33 per 100,000 U.S. children.[33] Child abuse fatalities are widely recognized as being
under-counted; it is estimated that between 60-85% of child fatalities due to maltreatment are not recorded as such
on death certificates. Younger children are at a much higher risk for being killed, as are African Americans. Girls
and boys, however, are killed at similar rates. Caregivers, and specifically mothers, are more likely to be the
perpetrators of a child abuse fatality, than anyone else, including strangers, relatives, and non-relative caregivers
[source needed]. Family situations which place children at risk include moving, unemployment, having non-family
members living in the household. A number of policies and programs have been put into place to try to better
understand and to prevent child abuse fatalities, including: safe-haven laws, child fatality review teams, training for
investigators, shaken baby syndrome prevention programs, and child abuse death laws which mandate harsher
sentencing for taking the life of a child.[34]
History
Also known as Tardieu's Syndrome in homage to the French medical doctor Auguste Ambroise Tardieu
Causes
Child abuse is a complex phenomenon with multiple causes.[35] Understanding the causes of abuse is crucial to
addressing the problem of child abuse.[36] Parents who physically abuse their spouses are more likely than others to
physically abuse their children.[37] However, it is impossible to know whether marital strife is a cause of child abuse,
or if both the marital strife and the abuse are caused by tendencies in the abuser.[37]
Children resulting from unintended pregnancies are more likely to be abused or neglected.[38] [39] In addition,
unintended pregnancies are more likely than intended pregnancies to be associated with abusive relationships,[40] and
there is an increased risk of physical violence during pregnancy.[41] They also result in poorer maternal mental
health,[41] and lower mother-child relationship quality.[41]
Substance abuse can be a major contributing factor to child abuse. One U.S. study found that parents with
documented substance abuse, most commonly alcohol, cocaine, and heroin, were much more likely to mistreat their
children, and were also much more likely to reject court-ordered services and treatments.[42] Another study found
that over two thirds of cases of child maltreatment involved parents with substance abuse problems. This study
specifically found relationships between alcohol and physical abuse, and between cocaine and sexual abuse.[43]
Unemployment and financial difficulties are associated with increased rates of child abuse.[44] In 2009 CBS News
reported that child abuse in the United States had increased during the economic recession. It gave the example of a
father who had never been the primary care-taker of the children. Now that the father was in that role, the children
began to come in with injuries.[45]
Studies have found that not biologically related parents (like stepparents) are up to a hundred times more likely to
kill a child than biological parents. An evolutionary psychology explanation for this is that using resources in order
to take care of another person's biological child is likely not a good strategy for increasing reproductive success.[46]
See also Infanticide (zoology). More generally, stepchildren have a much higher risk of being abused which is
sometimes referred to as the Cinderella effect.
128
Child abuse
129
Children are the Victims of Adult Vices, a group of sculptures by Mikhail Chemiakin in Moscow.
Effects
There are strong associations between exposure to child abuse in all its forms and higher rates of many chronic
conditions. The strongest evidence comes from the Adverse Childhood Experiences (ACE's) series of studies which
show correlations between exposure to abuse or neglect and higher rates in adulthood of chronic conditions,
high-risk health behaviors and shortened lifespan.[47] A recent publication, Hidden Costs in Health Care: The
Economic Impact of Violence and Abuse,[48] makes the case that such exposure represents a serious and costly
public-health issue that should be addressed by the healthcare system. Child abuse is a major life stressor that has
consequences involving the mental health of an adult but, the majority of studies examining the negative
consequences of abuse have been focused on adolescences and young adults. It has been identified that childhood
sexual abuse is a risk factor for the development of substance-related problems during adolescence and adulthood.
The early experiences of child abuse can trigger the development of an internalizing disorder, such as anxiety and
depression. For example, adults with a history of some form of child abuse, whether sexual abuse, physical abuse, or
neglect, have more chances of developing depression then an adult who has never been abused. Child abuse can also
cause problems with the neurodevelopment of a child. Research shows that abused children often develop deficits
with language, deregulation of mood, behaviour and also social/emotional disturbances. These risks are elevated
when child abuse is combined with traumatic events and/or fetal alcohol exposure.
Psychological effects
Children with a history of neglect or physical abuse are at risk of developing psychiatric problems,[49] [50] or a
disorganized attachment style.[51] [52] [53] Disorganized attachment is associated with a number of developmental
problems, including dissociative symptoms,[54] as well as anxiety, depressive, and acting out symptoms.[55] [56] A
study by Dante Cicchetti found that 80% of abused and maltreated infants exhibited symptoms of disorganized
attachment.[57] [58] When some of these children become parents, especially if they suffer from posttraumatic stress
disorder (PTSD), dissociative symptoms, and other sequelae of child abuse, they may encounter difficulty when
faced with their infant and young children's needs and normative distress, which may in turn lead to adverse
consequences for their child's social-emotional development.[59] [60] Despite these potential difficulties, psychosocial
intervention can be effective, at least in some cases, in changing the ways maltreated parents think about their young
children.[61]
Victims of childhood abuse, it is claimed, also suffer from different types of physical health problems later in life.
Some reportedly suffer from some type of chronic head, abdominal, pelvic, or muscular pain with no identifiable
reason.[62] Even though the majority of childhood abuse victims know or believe that their abuse is, or can be, the
cause of different health problems in their adult life, for the great majority their abuse was not directly associated
Child abuse
130
with those problems, indicating that sufferers were most likely diagnosed with other possible causes for their health
problems, instead of their childhood abuse.[62]
The effects of child abuse vary, depending on the type of abuse. A 2006 study found that childhood emotional and
sexual abuse were strongly related to adult depressive symptoms, while exposure to verbal abuse and witnessing of
domestic violence had a moderately strong association, and physical abuse a moderate one. For depression,
experiencing more than two kinds of abuse exerted synergetically stronger symptoms. Sexual abuse was particularly
deleterious in its intrafamilial form, for symptoms of depression, anxiety, dissociation, and limbic irritability.
Childhood verbal abuse had a stronger association with anger-hostility than any other type of abuse studied, and was
second only to emotional abuse in its relationship with dissociative symptoms. More generally, in the case of 23 of
the 27 illnesses listed in the questionnaire of a French INSEE survey, some statistically significant correlations were
found between repeated illness and family traumas encountered by the child before the age of 18 years.[63]
According to Georges Menahem, the French sociologist who found out these correlations by studying health
inequalities, these relationships show that inequalities in illness and suffering are not only social. Health inequality
also has its origins in the family, where it is associated with the degrees of lasting affective problems (lack of
affection, parental discord, the prolonged absence of a parent, or a serious illness affecting either the mother or
father) that individuals report having experienced in childhood.
Physical effects
Children who are physically abused are likely to receive bone
fractures, particularly rib fractures,[64] and may have a higher
risk of developing cancer.[65] Children who experience child
abuse & neglect are 59% more likely to be arrested as
juveniles, 28% more likely to be arrested as adults, and 30%
more likely to commit violent crime.[66]
The immediate physical effects of abuse or neglect can be
relatively minor (bruises or cuts) or severe (broken bones,
hemorrhage, or even death). In some cases the physical effects
are temporary; however, the pain and suffering they cause a
child should not be discounted. Meanwhile, the long-term
impact of child abuse and neglect on physical health is just
beginning to be explored. The long-term effects can be:
Rib fractures in an infant secondary to child abuse
Shaken baby syndrome. Shaking a baby is a common form of child abuse that often results in permanent
neurological damage (80% of cases) or death (30% of cases).[67] Damage results from intracranial hypertension
(increased pressure in the skull) after bleeding in the brain, damage to the spinal cord and neck, and rib or bone
fractures (Institute of Neurological Disorders and Stroke, 2007).
Impaired brain development. Child abuse and neglect have been shown, in some cases, to cause important regions of
the brain to fail to form or grow properly, resulting in impaired development (De Bellis & Thomas, 2003). These
alterations in brain maturation have long-term consequences for cognitive, language, and academic abilities
(Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006). NSCAW found more than three-quarters of foster
children between 1 and 2 years of age to be at medium to high risk for problems with brain development, as opposed
to less than half of children in a control sample (ACF/OPRE, 2004a).
Poor physical health. Several studies have shown a relationship between various forms of household dysfunction
(including childhood abuse) and poor health (Flaherty et al., 2006; Felitti, 2002). Adults who experienced abuse or
neglect during childhood are more likely to suffer from physical ailments such as allergies, arthritis, asthma,
bronchitis, high blood pressure, and ulcers (Springer, Sheridan, Kuo, & Carnes, 2007).[68]
Child abuse
On the other hand, there are some children who are raised in child abuse, but who manage to do unexpectedly well
later in life regarding the preconditions. Such children have been termed dandelion children, as inspired from the
way that dandelions seem to prosper irrespective of soil, sun, drought, or rain.[69] Such children (or currently
grown-ups) are of high interest in finding factors that mitigate the effects of child abuse.
Prevention
Unintended conception increases the risk of subsequent child abuse, and large family size increases the risk of child
neglect.[39] Thus a comprehensive study for the National Academy of Sciences concluded that affordable
contraceptive services should form the basis for child abuse prevention.[39] [70] "The starting point for effective child
abuse programming is pregnancy planning," according to an analysis for US Surgeon General C. Everett Koop.[39]
[71]
April has been designated Child Abuse Prevention Month in the United States since 1983.[72] U.S. President Barack
Obama continued that tradition by declaring April 2009 Child Abuse Prevention Month.[73] One way the Federal
government of the United States provides funding for child-abuse prevention is through Community-Based Grants
for the Prevention of Child Abuse and Neglect (CBCAP).[74]
Resources for child-protection services are sometimes limited. According to Hosin (2007), "a considerable number
of traumatized abused children do not gain access to protective child-protection strategies."[75] Briere (1992) argues
that only when "lower-level violence" of children ceases to be culturally tolerated will there be changes in the
victimization and police protection of children.[76]
Treatment
A number of treatments are available to victims of child abuse.[77] Trauma-focused cognitive behavioral therapy,
first developed to treat sexually abused children, is now used for victims of any kind of trauma. It targets
trauma-related symptoms in children including post-traumatic stress disorder (PTSD), clinical depression and
anxiety. It also includes a component for non-offending parents. Several studies have found that sexually abused
children undergoing TF-CBT improved more than children undergoing certain other therapies. Data on the effects of
TF-CBT for children who experienced only non-sexual abuse was not available as of 2006.[77]
Abuse-focused cognitive behavioral therapy was designed for children who have experienced physical abuse. It
targets externalizing behaviors and strengthens prosocial behaviors. Offending parents are included in the treatment,
to improve parenting skills/practices. It is supported by one randomized study.[77]
Child-parent psychotherapy was designed to improve the child-parent relationship following the experience of
domestic violence. It targets trauma-related symptoms in infants, toddlers, and preschoolers, including PTSD,
aggression, defiance, and anxiety. It is supported by two studies of one sample.[77]
Other forms of treatment include group therapy, play therapy, and art therapy. Each of these types of treatment can
be used to better assist the client, depending on the form of abuse they have experienced. Play therapy and art
therapy are ways to get children more comfortable with therapy by working on something that they enjoy (coloring,
drawing, painting, etc.). The design of a child's artwork can be a symbolic representation of what they are feeling,
relationships with friends or family, and more. Being able to discuss and analyze a child's artwork can allow a
professional to get a better insight of the child.[78]
131
Child abuse
Ethics
One of the most challenging ethical dilemmas arising from child abuse relates to the parental rights of abusive
parents or caretakers with regard to their children, particularly in medical settings.[79] In the United States, the 2008
New Hampshire case of Andrew Bedner drew attention to this legal and moral conundrum. Bedner, accused of
severely injuring his infant daughter, sued for the right to determine whether or not she remain on life support;
keeping her alive, which would have prevented a murder charge, created a motive for Bedner to act that conflicted
with the apparent interests of his child.[79] [80] [81] Bioethicists Jacob M. Appel and Thaddeus Mason Pope recently
argued, in separate articles, that such cases justify the replacement of the accused parent with an alternative
decision-maker.[79] [82]
Child abuse also poses ethical concerns related to confidentiality, as victims may be physically or psychologically
unable to report abuse to authorities. Accordingly, many jurisdictions and professional bodies have made exceptions
to standard requirements for confidentiality and legal privileges in instances of child abuse. Medical professionals,
including doctors, therapists, and other mental health workers typically owe a duty of confidentiality to their patients
and clients, either by law and/or the standards of professional ethics, and cannot disclose personal information
without the consent of the individual concerned. This duty conflicts with an ethical obligation to protect children
from preventable harm. Accordingly, confidentiality is often waived when these professionals have a good faith
suspicion that child abuse or neglect has occurred or is likely to occur and make a report to local child protection
authorities. This exception allows professionals to breach confidentiality and make a report even when the child or
his/her parent or guardian has specifically instructed to the contrary. Child abuse is also a common exception to
Physicianpatient privilege: a medical professional may be called upon to testify in court as to otherwise privileged
evidence about suspected child abuse despite the wishes of the child and his/her family.[83]
Organizations
There are organizations at national, state, and county levels in the United States that provide community leadership
in preventing child abuse and neglect. The National Alliance of Children's Trust Funds and Prevent Child Abuse
America are two national organizations with member organizations at the state level.
Many investigations into child abuse are handled on the local level by Child Advocacy Centers. Started over 25
years ago at what is now known as the National Children's Advocacy Center[84] in Huntsville, Alabama by District
Attorney Robert "Bud" Cramer these multi-disciplinary teams have met to coordinate their efforts so that cases of
child abuse can be investigated quickly and efficiently, ultimately reducing trauma to the child and garnering better
convictions.[85] [86] These Child Advocacy Centers (known as CACs) have standards set by the National Children's
Alliance.[87]
Other organizations focus on specific prevention strategies. The National Center on Shaken Baby Syndrome focuses
its efforts on the specific issue of preventing child abuse that is manifested as shaken baby syndrome. Mandated
reporter training is a program used to prevent ongoing child abuse.
132
Child abuse
References
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[11] "Child Sexual Abuse" (http:/ / www. nlm. nih. gov/ medlineplus/ childsexualabuse. html). Medline Plus. U.S. National Library of Medicine.
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[12] "Guidelines for psychological evaluations in child protection matters. Committee on Professional Practice and Standards, APA Board of
Professional Affairs". The American Psychologist 54 (8): 58693. August 1999. doi:10.1037/0003-066X.54.8.586. PMID10453704. "Abuse,
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[15] Brown, Patricia Leigh (May 23, 2011). "In Oakland, Redefining Sex Trade Workers as Abuse Victims" (http:/ / www. nytimes. com/ 2011/
05/ 24/ us/ 24oakland. html). The New York Times. . Retrieved May 24, 2011. "Once viewed as criminals and dispatched to juvenile centers,
where treatment was rare, sexually exploited youths are increasingly seen as victims of child abuse, with a new focus on early intervention and
counseling."
[16] Roosa M.W., Reinholtz C., Angelini P.J. (1999). "The relation of child sexual abuse and depression in young women: comparisons across
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(1): 6576. PMID10197407. .
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[18] Levitan, R. D., N. A. Rector, Sheldon, T., & Goering, P. (2003). " Childhood adversities associated with major depression and/or anxiety
disorders in a community sample of Ontario: Issues of co-morbidity and specificity (http:/ / www3. interscience. wiley. com/ cgi-bin/ abstract/
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[55] Lyons-Ruth, K. (February 1996). "Attachment relationships among children with aggressive behavior problems: the role of disorganized
early attachment patterns". Journal of Consulting and Clinical Psychology 64 (1): 6473. doi:10.1037/0022-006X.64.1.64. PMID8907085.
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Cicchetti, D.; Carlson, V.. Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect. Cambridge
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[58] Cicchetti, D. et al. (1990). "An organizational perspective on attachment beyond infancy". In Greenberg, M.; Cicchetti, D; MCummings, M..
Attachment in the Preschool Years. University of Chicago Press. pp.350. ISBN0226306291.
[59] >Schechter DS, Coates, SW, Kaminer T, Coots T, Zeanah CH, Davies M, Schonfield IS, Marshall RD, Liebowitz MR, Trabka KA, McCaw
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their toddlers". Journal of Trauma and Dissociation 9 (2): 123149. doi:10.1080/15299730802045666. PMC2577290. PMID18985165.
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adversely impacts young children's mental representations of self and others". Attachment & Human Development 9 (3): 187205.
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Liebowitz MR (2006). "Traumatized mothers can change their minds about their toddlers: Understanding how a novel use of video feedback
supports positive change of maternal attributions". Infant Mental Health Journal 27 (5): 429448. doi:10.1002/imhj.20101. PMC2078524.
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[62] Takele Hamnasu, MBA. Impact of Childhood Abuse on Adult Health. Amberton University.
[63] "Study of Living Conditions 1986-1987" INSEE survey with a sample of 13-154 individuals, cf. Menahem G., "Problmes de l'enfance,
statut social et sant des adultes", IRDES, biblio No 1010, pp. 59-63, Paris.
[64] Kemp AM, Dunstan F, Harrison S, et al. (2008). "Patterns of skeletal fractures in child abuse: systematic review" (http:/ / bmj. com/ cgi/
pmidlookup?view=long& pmid=18832412). BMJ 337 (oct02 1): a1518. doi:10.1136/bmj.a1518. PMC2563260. PMID18832412. .
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representative survey". Cancer 115 (14): 334150. doi:10.1002/cncr.24372. PMID19472404.
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[67] Morad Y, Wygnansky-Jaffe T, Levin AV (2010) Retinal haemorrhage in abusive head trauma. Clin Exp Ophthalmol 38:514-520.
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[69] Ellis, Bruce J.; Boyce, W. Thomas (2008). "Biological Sensitivity to Context". Current Directions in Psychological Science 17 (3):
183187. doi:10.1111/j.1467-8721.2008.00571.x.
[70] Baumrind (1993). Optimal Caregiving and Child Abuse: Continuities and Discontinuities. National Academy of Sciences Study Panel on
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[72] Child Welfare Information Gateway (http:/ / www. childwelfare. gov/ preventing/ preventionmonth/ history. cfm), History of National Child
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[73] Presidential Proclamation Marking National Child Abuse Prevention Month (http:/ / www. whitehouse. gov/ the_press_office/
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[75] Hosin, A.A., ed (2007). Responses to traumatized children. Basingstoke: Palgrave Macmillan. p.211. ISBN1403996806.
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[77] Cohen, J.A.; Mannarino, A.P.; Murray, L.K.; Igelman, R. (2006). "Psychosocial Interventions for Maltreated and Violence-Exposed
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[79] Appel, J.M. (October 2009). "Mixed motives, mixed outcomes when accused parents won't agree to withdraw care". Journal of Medical
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[80] "Springfield man denies charges in infant assault", Rutland Herald, New Hampshire, 5 August 2008.
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[82] "Withdrawal Okay When Surrogate's Refusal to Consent Based on Wrong Reasons" (http:/ / medicalfutility. blogspot. com/ 2009/ 10/
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[83] National Center for Youth Law. "Minor Consent, Confidentiality, and Child Abuse Reporting" (http:/ / www. youthlaw. org/ publications/
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[84] Nationalcac.org (http:/ / nationalcac. org/ index. html)
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[85] Nationalcac.org (http:/ / nationalcac. org/ professionals/ model/ cac_model. html)
[86] Nationalcac.org (http:/ / nationalcac. org/ ncac/ history. html)
[87] Nationalchildrensalliance.org (http:/ / www. nationalchildrensalliance. org/ )
Further reading
Crist, T. A. J.; Washburn, A.; Park, H.; Hood, I.; Hickey, M. A. (1997). "Cranial Bone Displacement as a
Taphonomic Process in Potential Child Abuse Cases". In Haglund, W. D. & Sorg, M. A.. Forensic Taphonomy:
the Postmortem Fate of Human Remains. Boca Raton: CRC Press. pp.319336.
Crosson-Tower, C. (2008). Understanding Child Abuse and Neglect. Boston, MA: Pearson Education.
ISBN0205503268. OCLC150902303.
Finkelhor, D. (2008-02-19). Childhood Victimization: Violence, Crime, and Abuse in the Lives of Young People
(http://books.google.com/?id=IOOgAFQdRPwC&printsec=frontcover). Oxford University Press. p.244.
ISBN9780195342857. OCLC162501989.
Hoyano, L.; Keenan C. (2007). Child Abuse: Law and Policy Across Boundaries. Oxford University Press.
ISBN019829946X. OCLC79004390.
Korbin, Jill E. (1983). Child abuse and neglect: cross-cultural perspectives. Berkeley, CA: University of
California Press. ISBN0520050703. OCLC144570871.
Turton, Jackie (2008). Child Abuse, Gender, and Society (http://books.google.com/?id=FDGaTSUXpdsC&
printsec=frontcover). New York: Routledge. p.161. ISBN0415365058. OCLC144570871.
External links
Cold-nosed Comfort - Maryland Lawyer article about using a facility service dog to aid child abuse victims (http:/
/www.courthousedogs.com/pdf/KellyBaltimoreCAC.pdf)
Pete - Award-winning short film about child abuse (http://www.youtube.com/watch?v=u2JXCFWcIeE)
Child abuse (http://www.dmoz.org/Society/Issues/Children,_Youth_and_Family/Child_abuse/) at the Open
Directory Project
"What is child abuse and neglect?" (http://www.oregon.gov/DHS/children/abuse/abuse_neglect.shtml),
Oregon Department of Human Services.
Prevent Child Abuse America (http://www.preventchildabuse.org)
Study on Child Abuse: India 2007 (http://wcd.nic.in/childabuse.pdf) Ministry of Women and Child
Development, Government of India (http://wcd.nic.in)
Prevent Child Abuse France (http://www.antipedophil.fr)
136
Human bonding
Human bonding
Human bonding is the process of development of a close, interpersonal relationship. It most commonly takes place
between family members or friends,[1] but can also develop among groups such as sporting teams and whenever
people spend time together. Bonding is a mutual, interactive process, and is different from simple liking.
Bonding typically refers to the process of attachment that develops between romantic partners, close friends, or
parents and children. This bond is characterized by emotions such as affection and trust. Any two people who spend
time together may form a bond. Male bonding refers to the establishment of relationships between men through
shared activities that often exclude females. The term female bonding is less frequently used, but refers to the
formation of close personal relationships between women.[2]
Etymology
The term comes from the 12th century, Middle English word band, which refers to something that binds, ties, or
restrains. In early usage, a bondman, bondwoman, or bondservant was a feudal serf that was obligated to work for
his or her lord without pay (in modern usage, a bondsman is a person who provides bonds or surety for someone).
Early views
In the 4th century BC, the Greek philosopher Plato argued that love directs the bonds of human society. In his
Symposium, Eryximachus, one of the narrators in the dialog, states that love goes far beyond simple attraction to
human beauty. He states that it occurs throughout the animal and plant kingdoms, as well as throughout the universe.
Love directs everything that occurs, in the realm of the gods as well as that of humans (186ab).
Eryximachus reasons that when various opposing elements such as wet and dry are "animated by the proper species
of Love, they are in harmony with one another ... But when the sort of Love that is crude and impulsive controls the
seasons, he brings death and destruction" (188a). Because it is love that guides the relations between these sets of
opposites throughout existence, in every case it is the higher form of love that brings harmony and cleaves toward
the good, whereas the impulsive vulgar love creates disharmony.
Plato concludes that the highest form of love is the greatest. When love "is directed, in temperance and justice,
towards the good, whether in heaven or on earth: happiness and good fortune, the bonds of human society, concord
with the gods aboveall these are among his gifts" (188d).
In the 1660s, the Dutch philosopher Spinoza wrote, in his Ethics of Human Bondage or the Strength of the Emotions,
that the term bondage relates to the human infirmity in moderating and checking the emotions. That is, according to
Spinoza, "when a man is prey to his emotions, he is not his own master, but lies at the mercy of fortune."
In 1809 Johann Wolfgang von Goethe, in his classic novella Elective Affinities, wrote of the "marriage tie," and by
analogy shows how strong marriage unions are similar in character to that by which the particles of quicksilver find a
unity together through the process of chemical affinity. Humans in passionate relationships, according to Goethe, are
analogous to reactive substances in a chemical equation.
Pair bonding
The term pair bond originated in 1940 in reference to mated pairs of birds. It is a generic term signifying a
monogamous or relatively monogamous relationship in either humans or animals. The term is commonly used in
sociobiology and evolutionary psychology.[3] Pair bonding, usually of a fairly short duration, occurs in a variety of
primate species. Some scientists speculate that prolonged bonds developed in humans along with increased sharing
of food.[4]
137
Human bonding
Limerent bond
According to limerence theory, posited in 1979 by psychologist Dorothy Tennov, a certain percentage of couples
may go through what is called a limerent reaction, in which one or both of the pair may experience a state of passion
mixed with continuous intrusive thinking, fear of rejection, and hope. Hence, with all human romantic relationships,
one of three varieties of bonds may form, defined over a set duration of time, in relation to the experience or
non-experience of limerence:
1. Affectional bond: define relationships in which neither partner is limerent.
2. LimerentNonlimerent bond: define relationships in which one partner is limerent.
3. LimerentLimerent bond: define relationships in which both partners are limerent.
The constitution of these bonds may vary over the course of the relationship, in ways that may either increase or
decrease the intensity of the limerence. The basis and interesting characteristic of this delineation made by Tennov,
is that based on her research and interviews with over 500 people, all human bonded relationships can be divided
into three varieties being defined by the amount of limerence or non-limerence each partner contributes to the
relationship.
Parental bonding
Attachment
In 1958, British developmental psychologist John Bowlby published
the ground-breaking paper "the Nature of the Child's Tie to his
Mother," in which the precursory concepts of "attachment theory" were
developed. This included the development of the concept of the
affectional bond, sometimes referred to as the emotional bond, which
is based on the universal tendency for humans to attach, i.e. to seek
closeness to another person and to feel secure when that person is
present. Attachment theory has some of its origins in the observation of
and experiments with animals, but is also based on observations of
children who had missed typical experiences of adult care. Much of the
early research on attachment in humans was done by John Bowlby and
his associates. Bowlby proposed that babies have an inbuilt need from
birth to make emotional attachments, i.e. bonds, because this increases
the chances of survival by ensuring that they receive the care they
need.[5] [6] [7] Bowlby did not describe mutuality in attachment. He
A mother breast feedinga process that
facilitates motherinfant bonding.
stated that attachment by mother was a pathological inversion and
described only behaviors of the infant. Ainsworth attempted to follow
this amazing tunnel vision, but found she could not avoid eye-to-eye contact with infant and mother. She was not
successful in the use of infant gaze because she did not differentiate frightened hyper-alert states from affectionate
interaction. Many developmental specialists elaborated Bowlby's ethological observations. However, neither
Bowlby's proximity seeking (not possible for human infants prior to walking) nor subsequent descriptions of
caregiverinfant mutuality with emotional availability and synchrony with emotional modulation include the
enduring motivation of attachment into adult life. The enduring motivation is the desire to control a pleasantly
surprising transformation that is the route of belief in effectiveness by humans. This motivation accounts for
curiosity and intellectual growth of language, mathematics and logic, all of which have an emotional base of
security.[8]
138
Human bonding
139
Maternal bonding
Of all human bonds, the maternal bond (motherinfant relationship) is one of the strongest. The maternal bond
begins to develop during pregnancy; following pregnancy, the production of oxytocin during lactation increases
parasympathetic activity, thus reducing anxiety and theoretically fostering bonding. It is generally understood that
maternal oxytocin circulation can predispose some mammals to show caregiving behavior in response to young of
their species.
Breastfeeding has been reported to foster the early post-partum maternal bond, via touch, response, and mutual
gazing.[9] Extensive claims for the effect of breastfeeding were made in the 1930s by Margaret Ribble, a champion
of "infant rights,"[10] but were challenged by others.[11] The claimed effect is not universal, and bottle-feeding
mothers are generally appropriately concerned with their babies. It is difficult to determine the extent of causality
due to a number of confounding variables, such as the varied reasons families choose different feeding methods.
Many believe that early bonding ideally increases response and sensitivity to the child's needs, bolstering the quality
of the motherbaby relationshiphowever, many exceptions can be found of highly successful motherbaby bonds,
even though early breastfeeding did not occur, such as with premature infants who may lack the necessary sucking
strength to successfully breastfeed.
Paternal bonding
In contrast to the maternal bond, paternal bonds tend to vary over the
span of a child's development in terms of both strength and stability. In
fact, many children now grow up in fatherless households and do not
experience a paternal bond at all. In general, paternal bonding is more
dominant later in a child's life after language develops. Fathers may be
more influential in play interactions as opposed to nurturance
interactions. Fatherchild bonds also tend to develop with respect to
topics such as political views or money, whereas motherchild bonds
tend to develop in relation to topics such as religious views or general
outlooks on life.[12]
In 2003, a researcher from Northwestern University in Illinois found
that progesterone, a hormone more usually associated with pregnancy
and maternal bonding, may also control the way men react towards
their children. Specifically, they found that a lack of progesterone
reduced aggressive behavior in male mice and stimulated them to act in
a fatherly way towards their offspring.[13]
Father playing with his young daughteran

activity that tends to strengthen the fatherchild
bond.
Human bonding
140
Humananimal bonding
The humananimal bond can be defined as a connection between
people and animals, domestic or wild; be it a cat as a pet or birds
outside one's window. Research into the nature and merit of the
humananimal bond began in the late 18th century when, in York,
England, the Society of Friends established The Retreat to provide
humane treatment for the mentally ill. By having patients care for the
many farm animals on the estate, society officials theorized that the
combination of animal contact plus productive work would facilitate
the patients' rehabilitation. In the 1870s in Paris, a French surgeon had
patients with neurological disorders ride horses. The patients were
found to have improved their motor control and balance and were less
likely to suffer bouts of depression.[14]
Humananimal bond: human to animal contact is

known to reduce the physiological characteristics
of stress.
In the 19th century, in Bielefeld, Germany, epileptic patients were

given the prescription to spend time each day taking care of cats and
dogs. The contact with the animals was found to reduce the occurrence
of seizures. In 1980, a team of scientists at the University of
Pennsylvania found that human to animal contact was found to reduce
the physiological characteristics of stress; specifically, lowered levels
of blood pressure, heart rate, respiratory rate, anxiety, and tension were
all found to correlate positively with humanpet bonding.[14]
Historically, animals were domesticated for functional use; for

example, dogs for herding and tracking, and cats for killing mice or
rats. Today, in Western societies, their function is primarily bonding.
For example, current studies show that 6080% of dogs sleep with
their owners at night in the bedroom, either in or on the bed.[15]
Moreover, in the past the majority of cats were kept outside (barn cats)
whereas
today most cats are kept indoors (housecats) and considered
Human bonding with an emu in Australia.
part of the family. Currently, in the US, for example, 1.2 billion
animals are kept as pets, primarily for bonding purposes.[15] In addition, as of 1995 there were over 30 research
institutions looking into the potential benefits of the humananimal bond.[14]
Neurobiology
There is evidence in a variety of species that the hormones oxytocin and vasopressin are involved in the bonding
process, and in other forms of prosocial and reproductive behavior. Both chemicals facilitate pair bonding and
maternal behavior in experiments on laboratory animals. In humans, there is evidence that oxytocin and vasopressin
are released during labor and breastfeeding, and that these events are associated with maternal bonding. According to
one model, social isolation leads to stress, which is associated with activity in the hypothalamic-pituitary-adrenal
axis
and
the
release
of
cortisol.
Positive
Human bonding
141
social interaction is associated with increased oxytocin. This leads to

bonding, which is also associated with higher levels of oxytocin and
vasopressin, and reduced stress and stress-related hormones.[16]
Oxytocin is associated with higher levels of trust in laboratory studies
on humans. It has been called the "cuddle chemical" for its role in
facilitating trust and attachment.[17] In the reward centers of the limbic
system, the neurotransmitter dopamine may interact with oxytocin and
further increase the likelihood of bonding. One team of researchers has
argued that oxytocin only plays a secondary role in affiliation, and that
endogenous opiates play the central role. According to this model,
affiliation is a function of the brain systems underlying reward and
memory formation.[18]
A small child bonding with a cat.
Because the vast majority of this research has been done on animalsand the majority of that on rodentsthese
findings must be taken with caution when applied to humans. One of the few studies that looked at the influence of
hormones on human bonding compared participants who had recently fallen in love with a control group. There were
no differences for most of the hormones measured, including LH, estradiol, progesterone, DHEAS, and
androstenedione. Testosterone and FSH were lower in men who had recently fallen in love, and there was also a
difference in blood cortisol for both sexes, with higher levels in the group that was in love. These differences
disappeared after 1228 months and may reflect the temporary stress and arousal of a new relationship.[19]
Weak ties
In 1962, while a freshman history major at Harvard, Mark Granovetter became enamored of the concepts underlying
the classic chemistry lecture in which "weak" hydrogen bonds hold huge numbers of water molecules together,
which themselves are held together by "strong" covalent bonds. This model was the stimulus behind his famous 1973
paper The Strength of Weak Ties, which is now considered a classic paper in sociology.
Weak social bonds are believed to be responsible for the majority of the embeddedness and structure of social
networks in society as well as the transmission of information through these networks. Specifically, more novel
information flows to individuals through weak than through strong ties. Because our close friends tend to move in
the same circles that we do, the information they receive overlaps considerably with what we already know.
Acquaintances, by contrast, know people that we do not, and thus receive more novel information.[20]
Human bonding
Debonding and loss

In 1976, sociologist Diane Vaughan proposed an "uncoupling theory," where, during the dynamics of relationship
breakup, there exists a "turning point," only noted in hindsight, followed by a transition period in which one partner
unconsciously knows the relationship is going to end, but holds on to it for an extended period, sometimes for a
number of years.[21]
When a person to which one has become bonded is lost, a grief response may occur. Grief is the process of accepting
the loss and adjusting to the changed situation. Grief may take longer than the initial development of the bond. The
grief process varies with culture.
References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
Websters New World College Dictionary 1996.

The Free Dictionary (http:/ / www. thefreedictionary. com)
Online Etymology Dictionary (http:/ / www. etymonline. com/ index. php?search=pair-bond& searchmode=none) Search: "pair bond"
Microsoft Encarta 2006. Premium Edition 19932005 Microsoft Corporation. All rights reserved.
Bowlby, John (1969). Attachment and Loss. Basic Books.
Bowlby, John (1990). The Making and Breaking of Affectional Bonds. Routledge. ISBN0415043263.
Wilson, Glenn; McLaughlin, Chris (2001). The Science of Love. Fusion Press. ISBN1-901250-54-7.
[8] See R.H. Smith; B.M. Ostfeld (1983), "Engageance, a practical elaboration of attachment in mothers of at-risk infants", International Journal
of Family Psychiatry 4 (3): 229245
[9] Cesk, Cas Lek. (2000). " Development of the Maternal Bond during Pregnancy (http:/ / www. findarticles. com/ p/ articles/ mi_qa3749/
is_200310/ ai_n9302754)." Jan 19 ; 139(1): 58.
[10] Ribble, M. (1939). The significance of infantile sucking for the psychic development of the individual. Journal of Nervous and Mental
Disease, 90, 455463.
[11] Pinneau, S.R. (1950). A critique on the articles by Margaret Ribble. Child Development, 21(4), 203228.
[12] Rossi, A. & Rossi, P. (1990). Of Human Bonding: Parent Child Relations Across the Life Course. Chicago: Aldine. ISBN 0-202-30361-6
[13] "Secret of paternal bond" (http:/ / news. bbc. co. uk/ 2/ low/ health/ 2793551. stm). BBC News. 25 February 2003. .
[14] Latter, L. (1995). Article: "Human Pet Bonding" (http:/ / www. animalwelfaresociety. net/ pethumanbonding. htm). Source: Animal Welfare
Society Southeastern Michigan.
[15] Article: "The Changing Status of HumanAnimal Bonds" (http:/ / www. censhare. umn. edu/ spotlight02. html). Source: University of
Minnesota.
[16] Carter, C.S. (1998). Neuroendocrine perspectives on social attachment and love. Psychoneuroendocrinology, 23, 779818.
[17] Ackerman, Diane (1994). A Natural History of Love. Vintage Books. ISBN0-679-76183-7.
[18] Depue, R.A., & Morrone-Strupinsky, J.V. (2005). A neurobehavioral model of affiliative bonding: Implications for conceptualizing a human
trait of affiliation. Behavioral and Brain Sciences, 28, 313395.
[19] Marazziti, D., & Canale, D. (2004). Hormonal changes when falling in love. Psychoneuroendocrinology, 29, 931936.
[20] Granovetter, M.D. (2004). " The Impact of Social Structures on Economic Development (http:/ / www. leader-values. com/ Content/ detail.
asp?ContentDetailID=990)." Journal of Economic Perspectives (Vol 19 Number 1, pp. 3350).
[21] Vaughan, Diane (1986). Uncoupling Turning Points in Intimate Relationships. Oxford University Press. ISBN0-679-73002-8.
Further reading
Books
Miller, W.B. & Rodgers, J.L. (2001). The Ontogeny of Human Bonding Systems: Evolutionary Origins, Neural
Bases, and Psychological Manifestations. New York: Springer. ISBN 0-7923-7478-9
Articles
Ben-Amos, I.K. (1997). "Human Bonding: Parents and Their Offspring in Early Modern England." (http://www.
nuff.ox.ac.uk/economics/history/paper17/17www.pdf) Discussion Papers in Economic and Social History
Oxford University.
Brown, S.L. & Brown, R.M. (2006). Selective investment theory: Recasting the functional significance of close
relationships. (http://www.si.umich.edu/ICOS/Brown-Stephanie.pdf) Psychological Inquiry, 17, 129. a
142
Human bonding
theoretical proposal that "human social bonds evolved as overarching, emotion regulating mechanisms designed
to promote reliable, high-cost altruism among individuals who depend on one another for survival and
reproduction" (From the abstract)
Immerman, R.S. & Mackey, W.C. (2003). Perspectives on Human Attachment (Pair Bonding): Eve's unique
legacy of canine analogue (http://human-nature.com/ep/articles/ep01138154.html) Evolutionary Psychology,
1, 138154. ISSN 1474-7049
Thorne, L. (2006). " Of Human Bonding (http://www.washingtonpost.com/wp-dyn/content/article/2006/08/
04/AR2006080400332.html)" Condo Dwellers Find Cool Ways to Connect With the Neighbors, Express
(Washingtonpost.com), Mon., (Aug. 07)
Author (2006). " Falling in Love: Insights into Human Bonding (http://www.wellcome.ac.uk/
doc_WTX033638.html)." Wellcome Trust, Aug. 25
External links
Relationships
Chemical Bonding and Love (http://people.howstuffworks.com/love7.htm) HowStuffWorks.com
Researchers Map the Sexual Network of an Entire High School (http://researchnews.osu.edu/archive/chains.
htm) Research News, Ohio State University
The Neurobiology of Social Bonds (http://www.neuroendo.org.uk/content/view/34/11/) British Society
for Neuroendocrinology
Baby bonding
Bonding With Your Baby (http://kidshealth.org/parent/pregnancy_newborn/communicating/bonding.html)
source: kidshealth.org
Bonding Period (http://www.birthingnaturally.net/barp/bonding.html) Parent/Infant Bonding
Bonding Matters the Chemistry of Attachment (http://www.babyreference.com/BondingMatters.htm)
Adoption bonding
Adoption bonding (http://www.adoptivefamilies.com/bonding/) Adoptive Families Magazine
Bonding and Attachment (http://encyclopedia.adoption.com/entry/bonding-and-attachment/72/1.html)
Encyclopedia of Adoption (use cautiously with section on "attachment disorders")
AICAN Australian Intercountry Adoption Network (http://www.aican.org/)
Humananimal bonding
ParrotHuman Bonding (http://www.quakerville.com/qic/bonding.asp) Progressive Steps in the Bonding
Process
FelineHuman Bond (http://cats.about.com/cs/felinehumanbond/a/bonding_bubba.htm?iam=metaresults&
terms=shannon+swallow) source: About.com
Equine Bonding Concepts (http://www.rosecreekvillage.com/ebc/)
143
Affectional bond
Affectional bond
In psychology, an affectional bond is a type of attachment behavior one individual has for another individual,[1]
typically a caregiver for her or his child,[2] in which the two partners tend to remain in proximity to one another.[1]
The term was coined and subsequently developed over the course of four decades, from the early 1940s to the late
1970s, by psychologist John Bowlby in his work on attachment theory. The core of the term affectional bond,
according to Bowlby, is the attraction one individual has for another individual. The central features of the concept
of affectional bonding can be traced to Bowlby's 1958 paper, "the Nature of the Child's Tie to his Mother."[3]
Five criteria
Bowlby referred to attachment bonds as a specific type of "affectional" bond, as described by him and developmental
psychologist Mary Ainsworth. She established five criteria for affectional bonds between individuals, and a sixth
criterion for attachment bonds:
1. An affectional bond is persistent, not transitory.
2. An affectional bond involves a particular person who is not interchangeable with anyone else.
3. An affectional bond involves a relationship that is emotionally significant.
4. The individual wishes to maintain proximity or contact with the person with whom he or she has an affectional
tie.
5. The individual feels sadness or distress at involuntary separation from the person.
An attachment bond has an additional criterion: the person seeks security and comfort in the relationship.[4]
References
[1]
[2]
[3]
[4]
Bowlby, J. (2005). The Making and Breaking of Affectional Bonds. Routledge Classics. ISBN0-415-35481-1.
http:/ / www. personalityresearch. org/ papers/ pendry. html
Bowlby, J. (1958). "The Nature of the Childs Tie to his Mother." International Journal of Psychoanalysis 39: 350373.
Ainsworth, M.D.S. (1989). Attachments beyond infancy. American Psychologist, 44, 709716. Reference for the entire section "Five criteria"
External links
Universality of Human Social Attachment as an Adaptive Process (http://web.fu-berlin.de/dahlem/DWR
92_Attachment/Chapter 10.pdf)
Attachment Security in Infancy and its Consequences for Development of the Individual (http://www.
turnertoys.com/security_and_attachment/default.htm)
144
John Bowlby
145
John Bowlby
Edward John Mostyn Bowlby
Full name Edward John Mostyn Bowlby
Born
26 February 1907
Died
2 September 1990 (aged83)
Edward John Mostyn "John" Bowlby (26 February 1907 2 September 1990) was a British psychologist,
psychiatrist and psychoanalyst, notable for his interest in child development and for his pioneering work in
attachment theory.
Family background
Bowlby was born in London to an upper-middle-class family. He was the fourth of six children and was brought up
by a nanny in the British fashion of his class at that time. His father, Sir Anthony Alfred Bowlby, first Baronet, was
surgeon to the King's Household, with a tragic history: at age five, Sir Anthony's own father, Thomas William
Bowlby, (John's grandfather) was killed while serving as a war correspondent in the Opium Wars.
Normally, Bowlby saw his mother only one hour a day after teatime, though during the summer she was more
available. Like many other mothers of her social class, she considered that parental attention and affection would
lead to dangerous spoiling of the children. Bowlby was lucky in that the nanny in his family was present throughout
his childhood.[1] When Bowlby was almost four years old, his beloved nanny, who was actually his primary
caretaker in his early years, left the family. Later, he was to describe this as tragic as the loss of a mother.
At the age of seven, he was sent off to boarding school, as was common for boys of his social status. In his work
Separation: Anxiety and Anger, he revealed that he regarded it as a terrible time for him. He later said, "I wouldn't
send a dog away to boarding school at age seven".[2] Because of such experiences as a child, he displayed a
sensitivity to childrens suffering throughout his life. However, with his characteristic attentiveness to the effects of
age differences, Bowlby did consider boarding schools appropriate for children aged eight and older, and wrote, "If
the child is maladjusted, it may be useful for him to be away for part of the year from the tensions which produced
his difficulties, and if the home is bad in other ways the same is true. The boarding school has the advantage of
preserving the child's all-important home ties, even if in slightly attenuated form, and, since it forms part of the
ordinary social pattern of most Western communities today [1951], the child who goes to boarding-school will not
feel different from other children. Moreover, by relieving the parents of the children for part of the year, it will be
possible for some of them to develop more favorable attitudes toward their children during the remainder."[3]
He married Ursula Longstaff, herself the daughter of a surgeon, on April 16, 1938, and they had four children,
including (Sir) Richard Bowlby, who succeeded his uncle as third Baronet.
Bowlby died at his summer home on the Isle of Skye, Scotland.
Career
Bowlby studied psychology and pre-clinical sciences at Trinity College, Cambridge, winning prizes for outstanding
intellectual performance. After Cambridge, he worked with maladjusted and delinquent children, then at the age of
twenty-two enrolled at University College Hospital in London. At the age of twenty-six, he qualified in medicine.
While still in medical school he enrolled himself in the Institute for Psychoanalysis. Following medical school, he
trained in adult psychiatry at the Maudsley Hospital. In 1937, aged 30, he qualified as a psychoanalyst.
John Bowlby
During World War II, he was a Lieutenant Colonel in the Royal Army Medical Corps. After the war, he was Deputy
Director of the Tavistock Clinic, and from 1950, Mental Health Consultant to the World Health Organization.
Because of his previous work with maladapted and delinquent children, he became interested in the development of
children and began work at the Child Guidance Clinic in London. This interest was probably increased by a variety
of wartime events involving separation of young children from familiar people; these included the rescue of Jewish
children by the Kindertransport arrangements, the evacuation of children from London to keep them safe from air
raids, and the use of group nurseries to allow mothers of young children to contribute to the war effort.[4] Bowlby
was interested from the beginning of his career in the problem of separation and the wartime work of Anna Freud
and Dorothy Burlingham on evacuees and Rene Spitz on orphans. By the late 1950s he had accumulated a body of
observational and theoretical work to indicate the fundamental importance for human development of attachment
from birth.[2]
Bowlby was interested in finding out the actual patterns of family interaction involved in both healthy and
pathological development. He focused on how attachment difficulties were transmitted from one generation to the
next. In his development of attachment theory he propounded the idea that attachment behaviour was essentially an
evolutionary survival strategy for protecting the infant from predators. Mary Ainsworth, a student of Bowlbys,
further extended and tested his ideas, and in fact played the primary role in suggesting that several attachment styles
existed. The three most important experiences for Bowlbys future work and the development of attachment theory
were his work with:
Maladapted and delinquent children.
James Robertson (in 1952) in making the documentary film A Two-Year Old Goes to the Hospital, which was one
of the films about young children in brief separation. The documentary illustrated the impact of loss and
suffering experienced by young children separated from their primary caretakers. This film was instrumental in a
campaign to alter hospital restrictions on visiting by parents. In 1952 when he and Robertson presented their film
A Two Year Old Goes to Hospital to the British Psychoanalytical Society, psychoanalysts did not accept that a
child would mourn or experience grief on separation but instead saw the child's distress as caused by elements of
unconscious fantasies (in the film because the mother was pregnant).[2]
Melanie Klein during his psychoanalytic training. She was his supervisor; however they had different views about
the role of the mother in the treatment of a three-year-old boy. Specifically and importantly, Klein stressed the
role of the child's fantasies about his mother, but Bowlby emphasized the actual history of the relationship.
Bowlby's viewsthat children were responding to real life events and not unconscious fantasieswere rejected
by psychoanalysts, and Bowlby was effectively ostracized by the psychoanalytic community. He later expressed
the view that his interest in real-life experiences and situations was "alien to the Kleinian outlook".[2]
In 1949, Bowlby's earlier work on delinquent and affectionless children and the effects of hospitalised and
institutionalised care lead to his being commissioned to write the World Health Organization's report on the mental
health of homeless children in post-war Europe.[5] The result was Maternal Care and Mental Health published in
1951.[6]
Bowlby drew together such limited empirical evidence as existed at the time from across Europe and the USA. His
main conclusions, that the infant and young child should experience a warm, intimate, and continuous relationship
with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment and that not to do
so may have significant and irreversible mental health consequences, were both controversial and influential. The
1951 WHO publication was highly influential in causing widespread changes in the practices and prevalence of
institutional care for infants and children, and in changing practices relating to the visiting of infants and small
children in hospitals by parents. The theoretical basis was controversial in many ways. He broke with psychoanalytic
theories which saw infants' internal life as being determined by fantasy rather than real life events. Some critics
146
John Bowlby
profoundly disagreed with the necessity for maternal (or equivalent) love in order to function normally,[7] or that the
formation of an ongoing relationship with a child was an important part of parenting.[8] Others questioned the extent
to which his hypothesis was supported by the evidence. There was criticism of the confusion of the effects of
privation (no primary attachment figure) and deprivation (loss of the primary attachment figure) and in particular, a
failure to distinguish between the effects of the lack of a primary attachment figure and the other forms of
deprivation and understimulation that may affect children in institutions.[9]
The monograph was also used for political purposes to claim any separation from the mother was deleterious in
order to discourage women from working and leaving their children in daycare by governments concerned about
maximising employment for returned and returning servicemen.[9] In 1962 WHO published Deprivation of maternal
care: A Reassessment of its Effects to which Mary Ainsworth, Bowlby's close colleague, contributed with his
approval, to present the recent research and developments and to address misapprehensions.[10] This publication also
attempted to address the previous lack of evidence on the effects of paternal deprivation.
According to Rutter the importance of Bowlby's initial writings on 'maternal deprivation' lay in his emphasis that
children's experiences of interpersonal relationships were crucial to their psychological development.[8]
Development of attachment theory

Bowlby himself explained in his 1988 work "A Secure Base" that the data were not, at the time of the publication of
Maternal Care and Mental Health, "accommodated by any theory then current and in the brief time of my
employment by the World Health Organization there was no possibility of developing a new one". He then went on
to describe the subsequent development of attachment theory.[11] Because he was dissatisfied with traditional
theories, Bowlby sought new understanding from such fields as evolutionary biology, ethology, developmental
psychology, cognitive science and control systems theory and drew upon them to formulate the innovative
proposition that the mechanisms underlying an infants tie emerged as a result of evolutionary pressure.[12] "Bowlby
realised that he had to develop a new theory of motivation and behaviour control, built on up-to-date science rather
than the outdated psychic energy model espoused by Freud."[5] Bowlby expressed himself as having made good the
"deficiencies of the data and the lack of theory to link alleged cause and effect" in Maternal Care and Mental Health
in his later work Attachment and Loss published in 1969.[13]
Ethology and evolutionary concepts

"From the 1950s Bowlby was in personal and scientific contact with leading European scientists in the field of
ethology, namely Niko Tinbergen, Konrad Lorenz, and especially the rising star of ethology Robert Hinde. Using the
viewpoints of this emerging science and reading extensively in the ethology literature, Bowlby developed new
explanatory hypotheses for what is now known as human attachment behaviour. In particular, on the basis of
ethological evidence he was able to reject the dominant Cupboard Love theory of attachment prevailing in
psychoanalysis and learning theory of the 1940s and 1950s. He also introduced the concepts of environmentally
stable or labile human behaviour allowing for the revolutionary combination of the idea of a species-specific genetic
bias to become attached and the concept of individual differences in attachment security as environmentally labile
strategies for adaptation to a specific childrearing niche. Alternatively, Bowlbys thinking about the nature and
function of the caregiver-child relationship influenced ethological research, and inspired students of animal
behaviour such as Tinbergen, Hinde, and Harry Harlow. Bowlby spurred Hinde to start his ground breaking work on
attachment and separation in primates (monkeys and humans), and in general emphasized the importance of
evolutionary thinking about human development that foreshadowed the new interdisciplinary approach of
evolutionary psychology. Obviously, the encounter of ethology and attachment theory led to a genuine
cross-fertilization" (Van der Horst, Van der Veer & Van IJzendoorn, 2007, p.321).[14] [15]
147
John Bowlby
The "Attachment and Loss" trilogy

Before the publication of the trilogy in 1969, 1972 and 1980, the main tenets of attachment theory, building on
concepts from ethology and developmental psychology, were presented to the British Psychoanalytical Society in
London in three now classic papers: The Nature of the Childs Tie to His Mother (1958), Separation Anxiety (1959),
and Grief and Mourning in Infancy and Early Childhood (1960). Bowlby rejected psychoanalyst explanations for
attachment, and in return, psychoanalysts rejected his theory. At about the same time, Bowlby's former colleague,
Mary Ainsworth was completing extensive observational studies on the nature of infant attachments in Uganda with
Bowlby's ethological theories in mind. Her results in this and other studies contributed greatly to the subsequent
evidence base of attachment theory as presented in 1969 in Attachment the first volume of the Attachment and Loss
trilogy.[16] The second and third volumes, Separation: Anxiety and Anger and Loss: Sadness and Depression
followed in 1972 and 1980 respectively. Attachment was revised in 1982 to incorporate recent research.
According to attachment theory, attachment in infants is primarily a process of proximity seeking to an identified
attachment figure in situations of perceived distress or alarm for the purpose of survival. Infants become attached to
adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent
caregivers for some months during the period from about 6 months to two years of age. Parental responses lead to
the development of patterns of attachment which in turn lead to 'internal working models' which will guide the
individual's feelings, thoughts, and expectations in later relationships.[5] In Bowlby's approach, the human infant is
considered to have a need for a secure relationship with adult caregivers, without which normal social and emotional
development will not occur.
As the toddler grows, it uses its attachment figure or figures as a "secure base" from which to explore. Mary
Ainsworth used this feature plus "stranger wariness" and reunion behaviours, other features of attachment behaviour,
to develop a research tool called the "Strange Situation Procedure" for developing and classifying different
attachment styles.
The attachment process is not gender specific as infants will form attachments to any consistent caregiver who is
sensitive and responsive in social interactions with the infant. The quality of the social engagement appears to be
more influential than amount of time spent.[16]
Darwin biography
Bowlby's last work, published posthumously, is a biography of Charles Darwin, which discusses Darwin's
"mysterious illness" and whether it was psychosomatic. [17]
Bowlby's legacy
Although not without its critics, attachment theory has been described as the dominant approach to understanding
early social development and to have given rise to a great surge of empirical research into the formation of children's
close relationships.[18] As it is presently formulated and used for research purposes, Bowlby's attachment theory
stresses the following important tenets:[19]
1. Children between 6 and about 30 months are very likely to form emotional attachments to familiar caregivers,
especially if the adults are sensitive and responsive to child communications.
2. The emotional attachments of young children are shown behaviourally in their preferences for particular familiar
people, their tendency to seek proximity to those people, especially in times of distress, and their ability to use the
familiar adults as a secure base from which to explore the environment.
3. The formation of emotional attachments contributes to the foundation of later emotional and personality
development, and the type of behaviour toward familiar adults shown by toddlers has some continuity with the
social behaviours they will show later in life.
148
John Bowlby
4. Events that interfere with attachment, such as abrupt separation of the toddler from familiar people or the
significant inability of carers to be sensitive, responsive or consistent in their interactions, have short-term and
possible long-term negative impacts on the child's emotional and cognitive life.
Notes
[1] Bowlby R and King P (2004). Fifty Years of Attachment Theory: Recollections of Donald Winnicott and John Bowlby. Karnac Books. p.17.
ISBN1855753855, 9781855753853.
[2] Schwartz J (1999). Cassandra's Daughter: A History of Psychoanalysis. Viking/Allen Lane. p.225. ISBN0670886238.
[3] Bowlby, J. (1951). Maternal Care and Mental Health.New York: Schocken.P.89.
[4] Mercer, J. (2006). 'Understanding attachment.' Westport,CT:Praeger.
[5] Bretherton I. "The Origins of Attachment Theory: John Bowlby and Mary Ainsworth" (1992) Developmental Psychology vol.28, pp. 759-775
[6] Bowlby, J (1951) Maternal Care and Mental Health, World Health Organisation WHO
[7] Wootton, B. (1962). "A Social Scientist's Approach to Maternal Deprivation." In Deprivation of Maternal Care: A Reassessment of its
Effects. Geneva: World Health Organization, Public Health Papers, No. 14. pp. 255-266
[8] Rutter, M (1995). "Clinical Implications of Attachment Concepts: Retrospect and Prospect". Journal of Child Psychology and Psychiatry 36
(4): 549571. doi:10.1111/j.1469-7610.1995.tb02314.x. PMID7650083.
[9] Rutter (1981) Maternal Deprivation Reassessed, Second edition, Harmondsworth, Penguin.
[10] Ainsworth M et al.(1962 ) Deprivation of Maternal Care: A Reassessment of its Effects. Geneva: World Health Organization, Public Health
Papers, No. 14.
[11] Bowlby J (1988) "A Secure Base: Clinical Applications of Attachment Theory". Routledge. London. ISBN 0-415-00640-6 (pbk)
[12] Cassidy J. (1999) "The Nature of a Childs Ties", in Handbook of Attachment. Eds. Cassidy J and Shaver PR. Guilford press.
[13] Bowlby J(1986) Citation Classic, Maternal Care and Mental Health (http:/ / www. garfield. library. upenn. edu/ classics1986/
A1986F063100001. pdf)
[14] Van der Horst FCP; Van der Veer R; Van IJzendoorn MH (2007). "John Bowlby and ethology: An annotated interview with Robert Hinde"
(http:/ / www. informaworld. com/ smpp/ content~content=a773405215). Attachment & Human Development 9 (4): 321335.
doi:10.1080/14616730601149809. PMID17852051. . Retrieved 2007-11-30.
[15] Van der Horst FCP; LeRoy HA; Van der Veer R (2008). ""When strangers meet": John Bowlby and Harry Harlow on attachment behavior"
(http:/ / www. springerlink. com/ content/ 47012q360531r664/ fulltext. pdf) (PDF). Integrative Psychological & Behavioral Science 42 (4):
370. doi:10.1007/s12124-008-9079-2. PMID18766423. . Retrieved 2008-09-11.
[16] Bowlby J [1969] (1999). Attachment, 2nd edition, Attachment and Loss (vol. 1), New York: Basic Books. LCCN 00266879; NLM 8412414.
ISBN 0-465-00543-8 (pbk). OCLC 11442968
[17] Bowlby, J, (1991). Charles Darwin: A New Life. New York: Norton.
[18] Schaffer R. Introducing Child Psychology. 2007. Blackwell.
[19] Mercer, J. (2006). Understanding Attachment. Westport, CT: Praeger.
Selected bibliography
Bowlby J (1995) [1950]. Maternal Care and Mental Health. The master work series (2nd ed.). Northvale, NJ;
London: Jason Aronson. ISBN1-56821-757-9. OCLC33105354. [Geneva, World Health Organization,
Monograph series no. 3].
Bowlby J (1976) [1965]. Fry M (abridged & ed.). ed (Report, World Health Organisation, 1953 (above)). Child
Care and the Growth of Love. Pelican books. Ainsworth MD (2 add. ch.) (2nd edn. ed.). London: Penguin Books.
ISBN0-14-013458-1. OCLC154150053.
Bowlby J (1999) [1969]. Attachment. Attachment and Loss (vol. 1) (2nd ed.). New York: Basic Books.
ISBN0-465-00543-8 (pbk). LCCN00266879;. OCLC11442968. NLM 8412414.
Bowlby J (1973). Separation: Anxiety & Anger. Attachment and Loss (vol. 2); (International psycho-analytical
library no.95). London: Hogarth Press. ISBN0712666214 (pbk). OCLC8353942.
Bowlby J (1980). Loss: Sadness & Depression. Attachment and Loss (vol. 3); (International psycho-analytical
library no.109). London: Hogarth Press. ISBN0-465-04238-4 (pbk). OCLC59246032.
Bowlby J (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. Tavistock
professional book. London: Routledge. ISBN0422622303 (pbk). OCLC42913724.
Bowlby J (1991). Charles Darwin: A New Life. New York: Norton. ISBN9780393309300.
149
John Bowlby
Bretherton I (September 1992). "The origins of attachment theory: John Bowlby and Mary Ainsworth".
Developmental Psychology 28 (5): 759775. doi:10.1037/0012-1649.28.5.759. OCLC1566542.
Holmes J (1993). John Bowlby and Attachment Theory. Makers of modern psychotherapy. London; New York:
Routledge. ISBN0-415-07730-3 (pbk). OCLC27266442.
Van Dijken S (1998). John Bowlby: His Early Life: A Biographical Journey into the Roots of Attachment Theory.
London; New York: Free Association Books. ISBN1853433934 (pbk). OCLC39982501.
Van Dijken S; Van der Veer R; Van IJzendoorn MH; Kuipers HJ (Summer 1998). "Bowlby before Bowlby: The
sources of an intellectual departure in psychoanalysis and psychology" (http://www3.interscience.wiley.com/
cgi-bin/abstract/76082/ABSTRACT). Journal of the History of the Behavioural Sciences 34 (3): 247269.
doi:10.1002/(SICI)1520-6696(199822)34:3<247::AID-JHBS2>3.0.CO;2-N. Retrieved 2007-09-01.
Mayhew B (November 2006). "Between love and aggression: The politics of John Bowlby". History of the
Human Sciences 19 (4): 1935. doi:10.1177/0952695106069666.
Van der Horst FCP; Van der Veer R; Van IJzendoorn MH (2007). "John Bowlby and ethology: An annotated
interview with Robert Hinde" (http://www.informaworld.com/smpp/content~content=a773405215).
Attachment & Human Development 9 (4): 321335. doi:10.1080/14616730601149809. PMID17852051.
Van der Horst FCP; LeRoy HA; Van der Veer R (2008). ""When strangers meet": John Bowlby and Harry
Harlow on attachment behavior" (http://www.springerlink.com/content/47012q360531r664/fulltext.pdf)
(PDF). Integrative Psychological & Behavioral Science 42 (4): 370. doi:10.1007/s12124-008-9079-2.
PMID18766423. Retrieved 2008-09-11.
Van der Horst FCP (2011). John Bowlby - From Psychoanalysis to Ethology. Unraveling the Roots of Attachment
Theory (http://www.amazon.com/John-Bowlby-Psychoanalysis-Unravelling-Attachment/dp/0470683643).
Oxford: Wiley-Blackwell. ISBN9780470683644.
External links
Summaries and links to full-text or articles and books by John Bowlby (http://www.richardatkins.co.uk/atws/
person/8.html)
John Bowlby: Attachment Theory Across Generations (http://video.google.com/
videoplay?docid=-6894776599072526990) 4-minute clip from a documentary film used primarily in higher
education.
John Bowlby - Rediscovering a systems scientist (http://isss.org/world/the-work-of-john-bowlby) A research
report by the International Society for the Systems Sciences authored by Gary Metcalf in 2010
150
Mary Ainsworth
151
Mary Ainsworth
Mary Ainsworth
Full name
Mary Ainsworth
Born
December 1, 1913
Glendale, Ohio
Died
March 21, 1999 (aged85)
Era
20th century philosophy
Region
Western Philosophy
School
Psychoanalysis
Maininterests Attachment theory

Notableideas
Finding of securely attached, insecurely attached - avoidant and ambivalent children
Mary Dinsmore Salter Ainsworth (December 1, 1913 March 21, 1999)[1] was a Canadian developmental
psychologist known for her work in early emotional attachment with "The Strange Situation" as well as her work in
the development of Attachment Theory.
Life
Ainsworth was born in Glendale, Ohio in 1913, eldest of three sisters. parents both graduated from Dickinson
College. Her father earned his Master's in History and was transferred to a manufacturing firm in Canada when
Ainsworth was five. While her parents always put a strong emphasis on education, it was William McDougall's book
Character and the Conduct of Life that inspired her interest in psychology.
Ainsworth enrolled in honors program in psychology at the University of Toronto in the fall of 1929. She earned her
B.A. in 1935, her M.A. in 1936, and her Ph.D in 1939, all from the University of Toronto. She stayed to teach for a
few years before joining the Canadian Women's Army Corp in 1942 in World War II, reaching the rank of Major in
1945.
She returned to Toronto to continue teaching personality psychology and conduct research. She married Leonard
Ainsworth in 1950 and moved to London with him to allow him to finish his graduate degree at University College.
After many other academic positions, she eventually settled at the University of Virginia in 1975, where she
remained the rest of her academic career. Ainsworth received many honors, including the Award for Distinguished
Contributions to Child Development in 1985 and the Distinguished Scientific Contribution Award from the APA in
1989. She was elected a Fellow of the American Academy of Arts and Sciences in 1992.[2]
Mary Ainsworth
Early work
While in England, Ainsworth joined the research team at Tavistock Clinic investigating the effects of maternal
separation on child development. Comparison of disrupted mother-child bonds to normal mother-child relationship
showed that a child's lack of a mother figure leads to "adverse development effects." In 1954, she left Tavistock
Clinic to do research in Africa, where she carried out her longitudinal field study of mother-infant interaction.
She and her colleagues developed the Strange Situation Procedure, which is a widely used, well researched and
validated, method of assessing an infant's pattern and style of attachment to a caregiver. (See Attachment theory.)
Strange Situation
In the 1970s, Ainsworth devised a procedure, called A Strange Situation, to observe attachment relationships
between a caregiver and child.
In this procedure of the strange situation the child is observed playing for 20 minutes while caregivers and strangers
enter and leave the room, recreating the flow of the familiar and unfamiliar presence in most children's lives. The
situation varies in stressfulness and the child's responses are observed. The child experiences the following
situations:
1. Parent and infant are introduced to the experimental room.
2.
3.
4.
5.
6.
7.
8.
Parent and infant are alone. Parent does not participate while infant explores.
Stranger enters, converses with parent, then approaches infant. Parent leaves inconspicuously.
First separation episode: Stranger's behaviour is geared to that of infant.
First reunion episode: Parent greets and comforts infant, then leaves again.
Second separation episode: Infant is alone.
Continuation of second separation episode: Stranger enters and gears behaviour to that of infant.
Second reunion episode: Parent enters, greets infant, and picks up infant; stranger leaves inconspicuously.
Four aspects of the child's behaviour are observed:

1.
2.
3.
4.
The amount of exploration (e.g. playing with new toys) the child engages in throughout.
The child's reactions to the departure of its caregiver.
The stranger anxiety (when the baby is alone with the stranger).
The child's reunion behaviour with its caregiver.
On the basis of their behaviors, the children were categorized into three groups, with a fourth added later. Each of
these groups reflects a different kind of attachment relationship with the caregiver.
Secure attachment
A child who is securely attached to its mother will explore freely while the mother is present, will engage with
strangers, will be visibly upset when the mother departs and happy to see the mother return. However, the child will
not engage with a stranger if their mother is not in the room.
Securely attached children are best able to explore when they have the knowledge of a secure base to return to in
times of need (also known as "rapprochement," meaning in French "bring together"). When assistance is given, this
bolsters the sense of security and also, assuming the mother's assistance is helpful, educates the child in how to cope
with the same problem in the future. Therefore, secure attachment can be seen as the most adaptive attachment style.
According to some psychological researchers, a child becomes securely attached when the mother is available and
able to meet the needs of the child in a responsive and appropriate manner. Others have pointed out that there are
also other determinants of the child's attachment, and that behavior of the parent may in turn be influenced by the
child's behavior.
152
Mary Ainsworth
Anxious-resistant insecure attachment

A child with an anxious-resistant attachment style is anxious of exploration and of strangers, even when the mother
is present. When the mother departs, the child is extremely distressed. The child will be ambivalent when she returns
- seeking to remain close to the mother but resentful, and also resistant when the mother initiates attention. When
reunited with the mother, the baby may also hit or push his mother when she approaches and fail to cling to her when
she picks him up.
According to some psychological researchers, this style develops from a mothering style which is engaged but on the
mother's own terms. That is, sometimes the child's needs are ignored until some other activity is completed and that
attention is sometimes given to the child more through the needs of the parent than from the child's initiation.
This is now more commonly known as amibivalent/resistant attachment as the child can't make up his mind about
what he wants; when he is held he wants to be left alone and when he is left he clings to the mother. Both ambivalent
attachments and avoidant attachments are types of insecure attachments which are less desirable than secure
attachments,[3] but ambivalent attachment tends to be indicative of more maladaptive parenting and indicates a
greater likelihood for attachment problems in the future.
Anxious-avoidant insecure attachment

A child with a problem of the mental health attachment style will avoid or ignore the caregiver - showing little
emotion when the caregiver departs or returns. The child may run away from the caregiver when s/he approaches and
fail to cling to her/him when picked up. The child will not explore very much regardless of who is there. Strangers
will not be treated much differently from the caregiver. There is not much emotional range regardless of who is in
the room or if it is empty.
This bad boy of attachment develops from a care-giving style which is more disengaged. The child's needs are
frequently not met and the child comes to believe that communication of needs has no influence on the caregiver.
Disorganized/disoriented attachment
A fourth category was added by Ainsworth's colleague Mary Main[4] and Ainsworth accepted the validity of this
modification.[5]
A child may cry during separation but avoid the mother when she returns or may approach the mother, then freeze or
fall to the floor. Some show stereotyped behaviour, rocking to and fro or repeatedly hitting themselves. Main and
Hesse[6] found that most of the mothers of these children had suffered major losses or other trauma shortly before or
after the birth of the infant and had reacted by becoming severely depressed.[5] In fact, 56% of mothers who had lost
a parent by death before they completed high school subsequently had children with disorganised attachments.[6]
Critique of the Strange Situation Protocol

Michael Rutter describes the procedure in the following terms in 'The Clinical Implications of Attachment Concepts'
from the Journal of Child Psychology and Psychiatry, Volume 36 No 4, pp.552553,[7]
"It is by no means free of limitations (see Lamb, Thompson, Gardener, Charnov & Estes, 1984).[8] To
begin with, it is very dependent on brief separations and reunions having the same meaning for all
children. This maybe a major constraint when applying the procedure in cultures, such as that in Japan
(see Miyake et al.,, 1985),[9] where infants are rarely separated from their mothers in ordinary
circumstances. Also, because older children have a cognitive capacity to maintain relationships when the
older person is not present, separation may not provide the same stress for them. Modified procedures
based on the Strange Situation have been developed for older preschool children (see Belsky et al.,
1994; Greenberg et al., 1990)[10] [11] but it is much more dubious whether the same approach can be
used in middle childhood. Also, despite its manifest strengths, the procedure is based on just 20 minutes
153
Mary Ainsworth
of behavior. It can be scarcely expected to tap all the relevant qualities of a child's attachment
relationships. Q-sort procedures based on much longer naturalistic observations in the home, and
interviews with the mothers have developed in order to extend the data base (see Vaughn & Waters,
1990).[12] A further constraint is that the coding procedure results in discrete categories rather than
continuously distributed dimensions. Not only is this likely to provide boundary problems, but also it is
not at all obvious that discrete categories best represent the concepts that are inherent in attachment
security. It seems much more likely that infants vary in their degree of security and there is need for a
measurement systems that can quantify individual variation".
Ecological validity and universality of Strange Situation attachment classification distributions
With respect to the ecological validity of the Strange Situation, a meta-analysis of 2,000 infant-parent dyads,
including several from studies with non-Western language and/or cultural bases found the global distribution of
attachment categorizations to be A (21%), B (65%), and C (14%) [13] This global distribution was generally
consistent with Ainsworth et al.'s (1978) original attachment classification distributions.
However, controversy has been raised over a few cultural differences in these rates of 'global' attachment
classification distributions. In particular, two studies diverged from the global distributions of attachment
classifications noted above. One study was conducted in North Germany [14] in which more avoidant (A) infants
were found than global norms would suggest, and the other in Sapporo, Japan [15] where more resistant (C) infants
were found. Of these two studies, the Japanese findings have sparked the most controversy as to the meaning of
individual differences in attachment behavior as originally identified by Ainsworth et al. (1978).
In a recent study conducted in Sapporo, Behrens, et al., 2007.[16] found attachment distributions consistent with
global norms using the six-year Main & Cassidy scoring system for attachment classification.[17] In addition to these
findings supporting the global distributions of attachment classifications in Sapporo, Behrens et al. also discuss the
Japanese concept of amae and its relevance to questions concerning whether the insecure-resistant (C) style of
interaction may be engendered in Japanese infants as a result of the cultural practice of amae.
Attachment measurement: discrete or continuous?
Regarding the issue of whether the breadth of infant attachment functioning can be captured by a categorical
classification scheme, it should be noted that continuous measures of attachment security have been developed
which have demonstrated adequate psychometric properties. These have been used either individually or in
conjunction with discrete attachment classifications in many published reports [see Richters et al., 1998;[18] Van
IJzendoorn et al., 1990).[19] ] The original Richters et al. (1998) scale is strongly related to secure versus insecure
classifications, correctly predicting about 90% of cases.[19] Readers further interested in the categorical versus
continuous nature of attachment classifications (and the debate surrounding this issue) should consult the paper by
Fraley and Spieker [20] and the rejoinders in the same issue by many prominent attachment researchers including J.
Cassidy, A. Sroufe, E. Waters & T. Beauchaine, and M. Cummings.
154
Mary Ainsworth
Major works
Ainsworth, M. and Bowlby, J. (1965). Child Care and the Growth of Love. London: Penguin Books.
Ainsworth, M. (1967). Infancy in Uganda. Baltimore: Johns Hopkins.
Ainsworth, M., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of Attachment. Hillsdale, NJ: Erlbaum.
References
[1] "Mary D. Ainsworth" (http:/ / www. americanancestors. org/ PageDetail. aspx?recordId=81821039). Social Security Death Index. . Retrieved
7 April 2011.
[2] "Book of Members, 1780-2010: Chapter A" (http:/ / www. amacad. org/ publications/ BookofMembers/ ChapterA. pdf). American Academy
of Arts and Sciences. . Retrieved 6 April 2011.
[3] Rathus, S. A. (2009) Psych. Mason: Cengage Learning
[4] Main, M and Solomon, J (1990). "Procedures for identifying infants as disorganised/disoriented during the Ainsworth Strange Situation".
M.T. Greenberg, D. Cicchetti and E.M. Cummings (eds) Attachment in the Preschool Years. Chicago, University of Chicago Press.
pp.121160.
[5] Colin Murray Parkes (2006). Love and Loss. Routledge, London and New York. p.13.
[6] Main, M and Hesse, E (1990). "Parents' unresolved traumatic experiences are related to infant disorganised attachment status". M.T.
Greenberg, D. Cicchetti and E.M. Cummings (eds) Attachment in the Preschool Years. Chicago, University of Chicago Press. pp.121160.
[7] Rutter, M. (1995). Clinical implications of attachment concepts: Retrospect and Prospect. Journal of Child Psychology and Psychiatry and
Allied Disciplines, 36, 549-571.
[8] Lamb, Thompson, Gardener, Charnov & Estes,(1984). Security of Infantile attachment as assessed in the 'Strange Situation'; its study and
biological interpretations. Behavioral and Brain Sciences, 7, 127-147
[9] Miyake, Chen, & Campos (1985). Infant temperament and mother's mode of interaction and attachment in Japan; an interim report; In I.
Bretherton & E Waters (Eds), Growing points of attachment theory and research. Monographs of the Society for Research in Child
Development, 50, Serial No 209, 276-297.
[10] Belsky, J. & Cassidy, J. (1994). Attachment Theory and Evidence. In M. Rutter & D. Hay (Eds) Development Through Life; A Handbook
For Clinicians (pp. 373-402). Oxford; Blackwell Scientific Publications.
[11] Greenberg, M. T., Cicchetti, D. & Cummings, M. (Eds), (1990). Attachment in the preschool years; theory research and intervention.
Chicago; University of Chicago Press.
[12] Vaughn, B. E. & Waters, E. (1990). Attachment behavior at home and in the laboratory. Child Development, 61, 1965-1973.
[13] Van IJzendoorn, M.H., & Kroonenberg, P.M. (1988). Cross-cultural patterns of attachment: A meta-analysis of the strange-situation. Child
Development, 59, 147-156.
[14] Grossmann, K.E., Grossmann, K., Huber, F., & Wartner, U. (1981). German children's behavior toward their mothers at 12 months and their
fathers at 18 months in Ainsworth's strange situation. International Journal of Behavioral Development, 4, 157-184.
[15] Takahashi, K. (1986). Examining the Strange-Situation procedure with Japanese mothers and 12-month old infants. Developmental
Psychology, 22, 265-270.
[16] Behrens, K. Y., Main, M., & Hesse, E. (2007). Mothers Attachment Status as Determined by the Adult Attachment Interview Predicts Their
6-Year-Olds Reunion Responses: A Study Conducted in Japan. Developmental Psychology, 43, 15531567.
[17] Main, M., & Cassidy, J. (1988). Categories of response to reunion with the parent at age 6: Predictable from infant attachment classifications
and stable over a 1-month period. Developmental Psychology, 24, 415-426.
[18] Richters, J. E., Waters, E., & Vaughn, B. E. (1988). Empirical classification of infant-mother relationships from interactive behavior and
crying during reunion. Child Development, 59, 512-522.
[19] Van IJzendoorn, M. H., & Kroonenberg, P. M. (1990). Cross-cultural consistency of coding the strange situation. Infant Behavior and
[20] Fraley, C. R., & Spieker, S. J. (2003). Are Infant Attachment Patterns Continuously or Categorically Distributed? A Taxometric Analysis of
Strange Situation Behavior. Developmental Psychology, 39, 387-404.
155
Mary Ainsworth
Further reading
O'Connell, A.N., & Rusoo, N.F. (1983). Models of achievement: Reflections of eminent women in psychology.
New York: Columbia University Press.
External links
Mary Ainsworth on The Psi Cafe (http://www.psy.pdx.edu/PsiCafe/KeyTheorists/Ainsworth.htm)
Women's Intellectual Contributions to the Study of Mind and Society (http://www.webster.edu/~woolflm/
ainsworth.html)
Articles by Mary Ainsworth including summaries and links to full-text (http://www.richardatkins.co.uk/atws/
person/1.html)
Mary Ainsworth: Attachment and the Growth of Love (http://video.google.com/
videoplay?docid=-3634664472704568591) 4-minute clip from a documentary film used primarily in higher
education.
Michael Rutter
For the motorcycle racer, see Michael Rutter (motorcycle racer)
Sir Michael L. Rutter (born 1934) is the first consultant of child psychiatry in the United Kingdom. He has been
described as the "father of child psychology".[1] Currently he is Professor of Developmental Psychopathology at the
Institute of Psychiatry, King's College London and consultant psychiatrist at the Maudsley Hospital, a post he has
held since 1966.
Early life
Rutter was the oldest child born to Alice (ne Rudman) & Frank Rutter.
Career
Rutter set up the Medical Research Council (UK) Child Psychiatry Research Unit in 1984 and the Social, Genetic
and Developmental Psychiatry Centre 10 years later, being honorary director of both until October 1998. He was
Deputy Chairman of the Wellcome Trust from 1999 to 2004, and has been a Trustee of the Nuffield Foundation
since 1992.
Rutter's work includes: early epidemiologic studies (Isle of Wight and Inner London); studies of autism involving a
wide range of scientific techniques and disciplines, including DNA study and neuroimaging; links between research
and practice; deprivation; influences of families and schools; genetics; reading disorders; biological and social,
protective and risk factors; interactions of biological and social factors; stress; longitudinal as well as epidemiologic
studies, including childhood and adult experiences and conditions; and continuities and discontinuities in normal and
pathological development. The British Journal of Psychiatry credits him with a number of "breakthroughs"[2] in these
areas. Rutter is also recognized as contributing centrally to the establishment of child psychiatry as a medical and
biopsychosocial specialty with a solid scientific base.[3]
He has published over 400 scientific papers and chapters and some 40 books. He was the European Editor for
Journal of Autism and Developmental Disorders from 1974 till 1994.
156
Michael Rutter
In 1972 Rutter published 'Maternal Deprivation Reassessed',[4]
which New Society describes as "a classic in the field of child
care".[4] in which he evaluated the maternal deprivation hypothesis
propounded by Dr John Bowlby in 1951.[5] Bowlby had proposed
that the infant and young child should experience a warm, intimate,
and continuous relationship with his mother (or permanent mother
substitute) in which both find satisfaction and enjoyment and that
not to do so may have significant and irreversible mental health
consequences. This theory was both influential and controversial.
Children playing
Rutter made a significant contribution, his 1981 monograph and
other papers (Rutter 1972; Rutter 1979) comprising the definitive empirical evaluation and update of Bowlby's early
work on maternal deprivation. He amassed further evidence, addressed the many different underlying social and
psychological mechanisms and showed that Bowlby was only partially right and often for the wrong reasons. Rutter
highlighted the other forms of deprivation found in institutional care, the complexity of separation distress and
suggested that anti-social behaviour was not linked to maternal deprivation as such but to family discord. The
importance of these refinements of the maternal deprivation hypothesis was to reposition it as a "vulnerability factor"
rather than a causative agent, with a number of varied influences determining which path a child will take.[4] [6]
After the end of the Ceasescu regime in Romania in 1989, Rutter led the English and Romanian Adoptees Study
Team, following many of the orphans adopted into Western families into their teens in a series of substantial studies
on the effects of early privation and deprivation across multiple domains affecting child development including
attachment and the development of new relationships. The results yielded some reason for optimism.[7]
Awards and honors

Rutter has honorary degrees from the Universities of Leiden, Louvain, Birmingham, Edinburgh, Chicago,
Minnesota, Ghent, Jyvskyl, Warwick, East Anglia, Cambridge and Yale. He has remained in practice until late
into his career and the Michael Rutter Centre for Children and Adolescents, based at Maudsley Hospital, London, is
named after him.
Rutter is an honorary member of the British Academy and is an elected Fellow of the Royal Society. He is a
Founding Fellow of the Academia Europaea [8] and the Academy of Medical Sciences [9] and was knighted in 1992.
The citation for his knighthood reads: Professor of Child and Adolescent Psychiatry, Institute of Psychiatry,
University of London.
References
[1] Pearce, J (2005). Eric Taylor: The cheerful pessimist. Child and Adolescent Mental Health,Feb;10(1):4041. (http:/ / www.
blackwell-synergy. com/ doi/ abs/ 10. 1111/ j. 1475-3588. 2005. 00115. x)
[2] Kolvin, I (1999). The contribution of Michael Rutter. British Journal of Psychiatry, Jun;174:471-475.
[3] Hartman, L (2003). Review of Green & Yule, Research and Innovation on the Road to Modern Child Psychiatry. Am J Psychiatry,
Jan;160:196-197. (http:/ / ajp. psychiatryonline. org/ cgi/ content/ full/ 160/ 1/ 196)
[4] Rutter, M (1981) Maternal Deprivation Reassessed, Second edition, Harmondsworth, Penguin.
[5] Bowlby, J (1951) Maternal Care and Mental Health, World Health Organisation WHO
[6] Holmes J. (1993) John Bowlby & Attachment Theory. Routledge. pp. 49-53. ISBN 0-415-07729-X
[7] Rutter, M (Jan/Feb 2002). "Nature, nurture, and development: From evangelism through science toward policy and practice". Child
Development 73 (1): 121. doi:10.1111/1467-8624.00388. ISSN0009-3920. PMID14717240.
[8] http:/ / www. iis. ee. ic. ac. uk/ ~e. gelenbe/ AEInformatics. html
[9] http:/ / www. acmedsci. ac. uk/ html
157
Attachment theory
158
Attachment theory
Attachment theory describes the dynamics
of long-term relationships between humans.
Its most important tenet is that an infant
needs to develop a relationship with at least
one primary caregiver for social and
emotional development to occur normally.
Attachment theory is an interdisciplinary
study encompassing the fields of
psychological, evolutionary, and ethological
theory. Immediately after WWII, homeless
and orphaned children presented many
difficulties,[1]
and
psychiatrist
and
psychoanalyst John Bowlby was asked by
the UN to write a pamphlet on the matter.
Later he went on to formulate attachment
theory.
For infants and toddlers, the "set-goal" of the attachment behavioural system is to
maintain or achieve proximity to attachment figures, usually the parents.
Infants become attached to adults who are sensitive and responsive in social interactions with them, and who remain
as consistent caregivers for some months during the period from about six months to two years of age. When an
infant begins to crawl and walk they begin to use attachment figures (familiar people) as a secure base to explore
from and return to. Parental responses lead to the development of patterns of attachment; these, in turn, lead to
internal working models which will guide the individual's perceptions, emotions, thoughts and expectations in later
relationships.[2] Separation anxiety or grief following the loss of an attachment figure is considered to be a normal
and adaptive response for an attached infant. These behaviours may have evolved because they increase the
probability of survival of the child.[3]
Infant behaviour associated with attachment is primarily the seeking of proximity to an attachment figure. To
formulate a comprehensive theory of the nature of early attachments, Bowlby explored a range of fields, including
evolutionary biology, object relations theory (a branch of psychoanalysis), control systems theory, and the fields of
ethology and cognitive psychology.[4] After preliminary papers from 1958 onwards, Bowlby published a complete
study in 3 volumes Attachment and Loss (196982).
Research by developmental psychologist Mary Ainsworth in the 1960s and 70s reinforced the basic concepts,
introduced the concept of the "secure base"[5] and developed a theory of a number of attachment patterns in infants:
secure attachment, insecure-avoidant attachment and insecure-ambivalent attachment. A fourth pattern, disorganized
attachment, was identified later.[6]
In the 1980s, the theory was extended to attachment in adults.[7] Other interactions may be construed as including
components of attachment behaviour; these include peer relationships at all ages, romantic and sexual attraction and
responses to the care needs of infants or the sick and elderly.
In the early days of the theory, academic psychologists criticized Bowlby, and the psychoanalytic community
ostracised him for his departure from psychoanalytical tenets;[8] however, attachment theory has since become "the
dominant approach to understanding early social development, and has given rise to a great surge of empirical
research into the formation of children's close relationships".[9] Later criticisms of attachment theory relate to
temperament, the complexity of social relationships, and the limitations of discrete patterns for classifications.
Attachment theory has been significantly modified as a result of empirical research, but the concepts have become
generally accepted.[8] Attachment theory has formed the basis of new therapies and informed existing ones, and its
Attachment theory
concepts have been used in the formulation of social and childcare policies to support the early attachment
relationships of children.[10]
Attachment
Within attachment theory, attachment means an affectional bond or tie
between an individual and an attachment figure (usually a caregiver).
Such bonds may be reciprocal between two adults, but between a child
and a caregiver these bonds are based on the child's need for safety,
security and protection, paramount in infancy and childhood. The
theory proposes that children attach to carers instinctively,[11] for the
purpose of survival and, ultimately, genetic replication.[12] The
biological aim is survival and the psychological aim is security.[9]
Attachment theory is not an exhaustive description of human
relationships, nor is it synonymous with love and affection, although
these may indicate that bonds exist. In child-to-adult relationships, the
child's tie is called the "attachment" and the caregiver's reciprocal
equivalent is referred to as the "care-giving bond".[12]
Infants form attachments to any consistent caregiver who is sensitive
and responsive in social interactions with them. The quality of the
social engagement is more influential than the amount of time spent.
The biological mother is the usual principal attachment figure, but the
Although it is usual for the mother to be the
primary
attachment figure, infants will form
role can be taken by anyone who consistently behaves in a "mothering"
attachments
to any caregiver who is sensitive and
way over a period of time. In attachment theory, this means a set of
responsive in social interactions with them.
behaviours that involves engaging in lively social interaction with the
infant and responding readily to signals and approaches.[13] Nothing in
the theory suggests that fathers are not equally likely to become principal attachment figures if they provide most of
the child care and related social interaction.[14]
Some infants direct attachment behaviour (proximity seeking) towards more than one attachment figure almost as
soon as they start to show discrimination between caregivers; most come to do so during their second year. These
figures are arranged hierarchically, with the principal attachment figure at the top.[15] The set-goal of the attachment
behavioural system is to maintain a bond with an accessible and available attachment figure.[16] "Alarm" is the term
used for activation of the attachment behavioural system caused by fear of danger. "Anxiety" is the anticipation or
fear of being cut off from the attachment figure. If the figure is unavailable or unresponsive, separation distress
occurs.[17] In infants, physical separation can cause anxiety and anger, followed by sadness and despair. By age three
or four, physical separation is no longer such a threat to the child's bond with the attachment figure. Threats to
security in older children and adults arise from prolonged absence, breakdowns in communication, emotional
unavailability or signs of rejection or abandonment.[16]
159
Attachment theory
Behaviours
The attachment behavioural system serves to maintain or achieve
closer proximity to the attachment figure.[18] Pre-attachment
behaviours occur in the first six months of life. During the first phase
(the first eight weeks), infants smile, babble and cry to attract the
attention of caregivers. Although infants of this age learn to
discriminate between caregivers, these behaviours are directed at
anyone in the vicinity. During the second phase (two to six months),
the infant increasingly discriminates between familiar and unfamiliar
adults, becoming more responsive towards the caregiver; following and
clinging are added to the range of behaviours. Clear-cut attachment
develops in the third phase, between the ages of six months and two
years. The infant's behaviour towards the caregiver becomes organised
Insecure attachment patterns can compromise
exploration and the achievement of
on a goal-directed basis to achieve the conditions that make it feel
[19]
self-confidence. A securely attached baby is free
secure.
By the end of the first year, the infant is able to display a
to concentrate on her or his environment.
range of attachment behaviours designed to maintain proximity. These
manifest as protesting the caregiver's departure, greeting the caregiver's
return, clinging when frightened and following when able.[20] With the development of locomotion, the infant begins
to use the caregiver or caregivers as a safe base from which to explore.[19] Infant exploration is greater when the
caregiver is present because the infant's attachment system is relaxed and it is free to explore. If the caregiver is
inaccessible or unresponsive, attachment behaviour is more strongly exhibited.[21] Anxiety, fear, illness and fatigue
will cause a child to increase attachment behaviours.[22] After the second year, as the child begins to see the carer as
an independent person, a more complex and goal-corrected partnership is formed.[23] Children begin to notice others'
goals and feelings and plan their actions accordingly. For example, whereas babies cry because of pain,
two-year-olds cry to summon their caregiver, and if that does not work, cry louder, shout or follow.[9]
Tenets
Common human attachment behaviours and emotions are adaptive. Human evolution has involved selection for
social behaviours that make individual or group survival more likely. The commonly observed attachment behaviour
of toddlers staying near familiar people would have had safety advantages in the environment of early adaptation,
and has such advantages today. Bowlby saw the environment of early adaptation as similar to current hunter-gatherer
societies.[24] There is a survival advantage in the capacity to sense possibly dangerous conditions such as
unfamiliarity, being alone or rapid approach. According to Bowlby, proximity-seeking to the attachment figure in the
face of threat is the "set-goal" of the attachment behavioural system.[17]
The attachment system is very robust and young humans form attachments easily, even in far less than ideal
circumstances.[25] In spite of this robustness, significant separation from a familiar caregiveror frequent changes
of caregiver that prevent the development of attachmentmay result in psychopathology at some point in later
life.[25] Infants in their first months have no preference for their biological parents over strangers. Preferences for
certain people, plus behaviours which solicit their attention and care, are developed over a considerable period of
time.[25] When an infant is upset by separation from their caregiver, this indicates that the bond no longer depends on
the presence of the caregiver, but is of an enduring nature.[9]
160
Attachment theory
Early experiences with caregivers gradually give

rise to a system of thoughts, memories, beliefs,
expectations, emotions and behaviours about the
self and others.
161
Bowlby's original sensitivity period of between six months and two to
three years has been modified to a less "all or nothing" approach. There
is a sensitive period during which it is highly desirable that selective
attachments develop, but the time frame is broader and the effect less
fixed and irreversible than first proposed. With further research,
authors discussing attachment theory have come to appreciate that
social development is affected by later as well as earlier
relationships.[8] Early steps in attachment take place most easily if the
infant has one caregiver, or the occasional care of a small number of
other people.[25] According to Bowlby, almost from the first many
children have more than one figure towards whom they direct
attachment behaviour. These figures are not treated alike; there is a
strong bias for a child to direct attachment behaviour mainly towards
one particular person. Bowlby used the term "monotropy" to describe
this bias.[26] Researchers and theorists have abandoned this concept
insofar as it may be taken to mean that the relationship with the special
figure differs qualitatively from that of other figures. Rather, current
thinking postulates definite hierarchies of relationships.[8] [27]
Early experiences with caregivers gradually give rise to a system of

thoughts, memories, beliefs, expectations, emotions, and behaviours about the self and others. This system, called
the "internal working model of social relationships", continues to develop with time and experience.[28] Internal
models regulate, interpret and predict attachment-related behaviour in the self and the attachment figure. As they
develop in line with environmental and developmental changes, they incorporate the capacity to reflect and
communicate about past and future attachment relationships.[2] They enable the child to handle new types of social
interactions; knowing, for example, that an infant should be treated differently from an older child, or that
interactions with teachers and parents share characteristics. This internal working model continues to develop
through adulthood, helping cope with friendships, marriage and parenthood, all of which involve different
behaviours and feelings.[28] [29] The development of attachment is a transactional process. Specific attachment
behaviours begin with predictable, apparently innate, behaviours in infancy. They change with age in ways that are
determined partly by experiences and partly by situational factors.[30] As attachment behaviours change with age,
they do so in ways shaped by relationships. A child's behaviour when reunited with a caregiver is determined not
only by how the caregiver has treated the child before, but on the history of effects the child has had on the
caregiver.[31] [32]
Changes in attachment during childhood and adolescence

Age, cognitive growth and continued social experience advance the development and complexity of the internal
working model. Attachment-related behaviours lose some characteristics typical of the infant-toddler period and take
on age-related tendencies. The preschool period involves the use of negotiation and bargaining.[33] For example,
four-year-olds are not distressed by separation if they and their caregiver have already negotiated a shared plan for
the separation and reunion.[34]
Attachment theory
Ideally, these social skills become incorporated into the internal

working model to be used with other children and later with adult
peers. As children move into the school years at about six years old,
most develop a goal-corrected partnership with parents, in which each
partner is willing to compromise in order to maintain a gratifying
relationship.[33] By middle childhood, the goal of the attachment
behavioural system has changed from proximity to the attachment
figure to availability. Generally, a child is content with longer
separations, provided contactor the possibility of physically
reuniting, if neededis available. Attachment behaviours such as
clinging and following decline and self-reliance increases.[35] By
middle childhood (ages 711), there may be a shift towards mutual
coregulation of secure-base contact in which caregiver and child
negotiate methods of maintaining communication and supervision as
the child moves towards a greater degree of independence.[33]
162
Peers become important in middle childhood and

have an influence distinct from that of parents.
In early childhood, parental figures remain the centre of a child's social world, even if they spend substantial periods
of time in alternative care. This gradually lessens, particularly during the child's entrance into formal schooling.[35]
The attachment models of young children are typically assessed in relation to particular figures, such as parents or
other caregivers. There appear to be limitations in their thinking that restrict their ability to integrate relationship
experiences into a single general model. Children usually begin to develop a single general model of attachment
relationships during adolescence, although this may occur in middle childhood.[35]
Relationships with peers have an influence on the child that is distinct from that of parent-child relationships, though
the latter can influence the peer relationships children form.[9] Although peers become important in middle
childhood, the evidence suggests peers do not become attachment figures, though children may direct attachment
behaviours at peers if parental figures are unavailable. Attachments to peers tend to emerge in adolescence, although
parents continue to be attachment figures.[35] With adolescents, the role of the parental figures is to be available
when needed while the adolescent makes excursions into the outside world.[36]
Attachment patterns
Much of attachment theory was informed by Mary Ainsworth's innovative methodology and observational studies,
particularly those undertaken in Scotland and Uganda. Ainsworth's work expanded the theory's concepts and enabled
empirical testing of its tenets.[5] Using Bowlby's early formulation, she conducted observational research on
infant-parent pairs (or dyads) during the child's first year, combining extensive home visits with the study of
behaviours in particular situations. This early research was published in 1967 in a book titled Infancy in Uganda.[5]
Ainsworth identified three attachment styles, or patterns, that a child may have with attachment figures: secure,
anxious-avoidant (insecure) and anxious-ambivalent or resistant (insecure). She devised a procedure known as the
Strange Situation Protocol as the laboratory portion of her larger study, to assess separation and reunion
behaviour.[37] This is a standardised research tool used to assess attachment patterns in infants and toddlers. By
creating stresses designed to activate attachment behaviour, the procedure reveals how very young children use their
caregiver as a source of security.[9] Carer and child are placed in an unfamiliar playroom while a researcher records
specific behaviours, observing through a one-way mirror. In eight different episodes, the child experiences
separation from/reunion with the carer and the presence of an unfamiliar stranger.[37]
Ainsworth's work in the United States attracted many scholars into the field, inspiring research and challenging the
dominance of behaviourism.[38] Further research by Mary Main and colleagues at the University of California,
Berkeley identified a fourth attachment pattern, called disorganized/disoriented attachment. The name reflects these
Attachment theory
163
children's lack of a coherent coping strategy.[39]

The type of attachment developed by infants depends on the quality of care they have received.[40] Each of the
attachment patterns is associated with certain characteristic patterns of behaviour, as described in the following table:
[37] [39]
Child and caregiver behaviour patterns before the age of 18 months

Attachment
pattern
Child
Caregiver
Secure
Uses caregiver as a secure base for exploration. Protests

Responds appropriately, promptly
caregiver's departure and seeks proximity and is comforted
and consistently to needs. Caregiver
on return, returning to exploration. May be comforted by the has successfully formed a secure
stranger but shows clear preference for the caregiver.
parental attachment bond to the
child.
Avoidant
Little affective sharing in play. Little or no distress on

departure, little or no visible response to return, ignoring or
turning away with no effort to maintain contact if picked up.
Treats the stranger similarly to the caregiver. The child feels
that there is no attachment; therefore, the child is rebellious
and has a lower self-image and self-esteem.
Little or no response to distressed

child. Discourages crying and
encourages independence.
Ambivalent/Resistant Unable to use caregiver as a secure base, seeking proximity

Inconsistent between appropriate
before separation occurs. Distressed on separation with
and neglectful responses. Generally
ambivalence, anger, reluctance to warm to caregiver and
will only respond after increased
return to play on return. Preoccupied with caregiver's
attachment behavior from the infant.
availability, seeking contact but resisting angrily when it is
achieved. Not easily calmed by stranger. In this relationship,
the child always feels anxious because the caregiver's
availability is never consistent.
Disorganized
Stereotypies on return such as freezing or rocking. Lack of

coherent attachment strategy shown by contradictory,
disoriented behaviours such as approaching but with the
back turned.
Frightened or frightening behaviour,

intrusiveness, withdrawal, negativity,
role confusion, affective
communication errors and
maltreatment. Very often associated
with many forms of abuse towards
the child.
The presence of an attachment is distinct from its quality. Infants form attachments if there is someone to interact
with, even if mistreated. Individual differences in the relationships reflect the history of care, as infants begin to
predict the behaviour of caregivers through repeated interactions.[41] The focus is the organisation (pattern) rather
than quantity of attachment behaviours. Insecure attachment patterns are non-optimal as they can compromise
exploration, self-confidence and mastery of the environment. However, insecure patterns are also adaptive, as they
are suitable responses to caregiver unresponsiveness. For example, in the avoidant pattern, minimising expressions
of attachment even in conditions of mild threat may forestall alienating caregivers who are already rejecting, thus
leaving open the possibility of responsiveness should a more serious threat arise.[41]
Around 65% of children in the general population may be classified as having a secure pattern of attachment, with
the remaining 35% being divided between the insecure classifications.[42] Recent research has sought to ascertain the
extent to which a parent's attachment classification is predictive of their children's classification. Parents' perceptions
of their own childhood attachments were found to predict their children's classifications75% of the time.[43] [44] [45]
Over the short term, the stability of attachment classifications is high, but becomes less so over the long term.[9] It
appears that stability of classification is linked to stability in caregiving conditions. Social stressors or negative life
eventssuch as illness, death, abuse or divorceare associated with instability of attachment patterns from infancy
to early adulthood, particularly from secure to insecure.[46] Conversely, these difficulties sometimes reflect particular
Attachment theory
upheavals in people's lives, which may change. Sometimes, parents' responses change as the child develops,
changing classification from insecure to secure. Fundamental changes can and do take place after the critical early
period.[47] Physically abused and neglected children are less likely to develop secure attachments, and their insecure
classifications tend to persist through the pre-school years. Neglect alone is associated with insecure attachment
organisations, and rates of disorganized attachment are markedly elevated in maltreated infants.[40]
This situation is complicated by difficulties in assessing attachment classification in older age groups. The Strange
Situation procedure is for ages 12 to 18 months only;[9] adapted versions exist for pre-school children.[48]
Techniques have been developed to allow verbal ascertainment of the child's state of mind with respect to
attachment. An example is the "stem story", in which a child is given the beginning of a story that raises attachment
issues and asked to complete it. For older children, adolescents and adults, semi-structured interviews are used in
which the manner of relaying content may be as significant as the content itself.[9] However, there are no
substantially validated measures of attachment for middle childhood or early adolescence (approximately 7 to 13
years of age).[48]
Some authors have questioned the idea that a taxonomy of categories representing a qualitative difference in
attachment relationships can be developed. Examination of data from 1,139 15-month-olds showed that variation in
attachment patterns was continuous rather than grouped.[49] This criticism introduces important questions for
attachment typologies and the mechanisms behind apparent types. However, it has relatively little relevance for
attachment theory itself, which "neither requires nor predicts discrete patterns of attachment".[50]
Significance of attachment patterns

There is an extensive body of research demonstrating a significant association between attachment organisations and
children's functioning across multiple domains.[40] Early insecure attachment does not necessarily predict
difficulties, but it is a liability for the child, particularly if similar parental behaviours continue throughout
childhood.[47] Compared to that of securely attached children, the adjustment of insecure children in many spheres of
life is not as soundly based, putting their future relationships in jeopardy. Although the link is not fully established
by research and there are other influences besides attachment, secure infants are more likely to become socially
competent than their insecure peers. Relationships formed with peers influence the acquisition of social skills,
intellectual development and the formation of social identity. Classification of children's peer status (popular,
neglected or rejected) has been found to predict subsequent adjustment.[9] Insecure children, particularly avoidant
children, are especially vulnerable to family risk. Their social and behavioural problems increase or decline with
deterioration or improvement in parenting. However, an early secure attachment appears to have a lasting protective
function.[51] As with attachment to parental figures, subsequent experiences may alter the course of development.[9]
The most concerning pattern is disorganized attachment. About 80% of maltreated infants are likely to be classified
as disorganized, as opposed to about 12% found in non-maltreated samples. Only about 15% of maltreated infants
are likely to be classified as secure. Children with a disorganized pattern in infancy tend to show markedly disturbed
patterns of relationships. Subsequently their relationships with peers can often be characterised by a "fight or flight"
pattern of alternate aggression and withdrawal. Affected maltreated children are also more likely to become
maltreating parents. A minority of maltreated children do not, instead achieving secure attachments, good
relationships with peers and non-abusive parenting styles.[9] The link between insecure attachment, particularly the
disorganized classification, and the emergence of childhood psychopathology is well-established, although it is a
non-specific risk factor for future problems, not a pathology or a direct cause of pathology in itself.[40] In the
classroom, it appears that ambivalent children are at an elevated risk for internalising disorders, and avoidant and
disorganized children, for externalising disorders.[51]
One explanation for the effects of early attachment classifications may lie in the internal working model mechanism.
Internal models are not just "pictures" but refer to the feelings aroused. They enable a person to anticipate and
interpret another's behaviour and plan a response. If an infant experiences their caregiver as a source of security and
164
Attachment theory
165
support, they are more likely to develop a positive self-image and expect positive reactions from others. Conversely,
a child from an abusive relationship with the caregiver may internalise a negative self-image and generalise negative
expectations into other relationships. The internal working models on which attachment behaviour is based show a
degree of continuity and stability. Children are likely to fall into the same categories as their primary caregivers
indicating that the caregivers' internal working models affect the way they relate to their child. This effect has been
observed to continue across three generations. Bowlby believed that the earliest models formed were the most likely
to persist because they existed in the subconscious. Such models are not, however, impervious to change given
further relationship experiences; a minority of children have different attachment classifications with different
caregivers.[9]
There is some evidence that gender differences in attachment patterns of adaptive significance begin to emerge in
middle childhood. Insecure attachment and early psychosocial stress indicate the presence of environmental risk (for
example poverty, mental illness, instability, minority status, violence). This can tend to favour the development of
strategies for earlier reproduction. However, different patterns have different adaptive values for males and females.
Insecure males tend to adopt avoidant strategies, whereas insecure females tend to adopt anxious/ambivalent
strategies, unless they are in a very high risk environment. Adrenarche is proposed as the endocrine mechanism
underlying the reorganisation of insecure attachment in middle childhood.[46]
Attachment in adults
Attachment theory was extended to adult romantic relationships in the late 1980s by Cindy Hazan and Phillip
Shaver. Four styles of attachment have been identified in adults: secure, anxious-preoccupied, dismissive-avoidant
and fearful-avoidant. These roughly correspond to infant classifications: secure, insecure-ambivalent,
insecure-avoidant and disorganized/disoriented.
Securely attached adults tend to have positive views of themselves, their partners and their relationships. They feel
comfortable with intimacy and independence, balancing the two. Anxious-preoccupied adults seek high levels of
intimacy, approval and responsiveness from partners, becoming overly dependent. They tend to be less trusting, have
less positive views about themselves and their partners, and may exhibit high levels of emotional expressiveness,
worry and impulsiveness in their relationships. Dismissive-avoidant adults desire a high level of independence, often
appearing to avoid attachment altogether. They view themselves as self-sufficient, invulnerable to attachment
feelings and not needing close relationships. They tend to suppress their feelings, dealing with rejection by
distancing themselves from partners of whom they often have a poor opinion. Fearful-avoidant adults have mixed
feelings about close relationships, both desiring and feeling uncomfortable with emotional closeness. They tend to
mistrust their partners and view themselves as unworthy. Like dismissive-avoidant adults, fearful-avoidant adults
tend to seek less intimacy, suppressing their feelings.[7] [52] [53] [54]
Two main aspects of adult attachment have been studied. The
organisation and stability of the mental working models that underlie
the attachment styles is explored by social psychologists interested in
romantic attachment.[55] [56] Developmental psychologists interested in
the individual's state of mind with respect to attachment generally
explore how attachment functions in relationship dynamics and
impacts relationship outcomes. The organisation of mental working
models is more stable while the individual's state of mind with respect
to attachment fluctuates more. Some authors have suggested that adults
do not hold a single set of working models. Instead, on one level they
have a set of rules and assumptions about attachment relationships in
Attachment styles in adult romantic relationships

roughly correspond to attachment styles in infants
but adults can hold different internal working
models for different relationships.
Attachment theory
general. On another level they hold information about specific relationships or relationship events. Information at
different levels need not be consistent. Individuals can therefore hold different internal working models for different
relationships.[56] [57]
There are a number of different measures of adult attachment, the most common being self report questionnaires and
coded interviews based on the Adult Attachment Interview. The various measures were developed primarily as
research tools, for different purposes and addressing different domains, for example romantic relationships, parental
relationships or peer relationships. Some classify an adult's state of mind with respect to attachment and attachment
patterns by reference to childhood experiences, while others assess relationship behaviours and security regarding
parents and peers.[58]
History
Earlier theories
The concept of infants' emotional attachment to caregivers has been known anecdotally for hundreds of years. From
the late 19th century onward, psychologists and psychiatrists suggested theories about the existence or nature of
early relationships.[59] Early Freudian theory had little to say about a child's relationship with the mother, postulating
only that the breast was the love object.[60] Freudians attributed the infant's attempts to stay near the familiar person
to motivation learned through feeding and gratification of libidinal drives. In the 1930s, British developmental
psychologist Ian Suttie suggested that the child's need for affection was a primary one, not based on hunger or other
physical gratifications.[61] William Blatz, a Canadian psychologist and teacher of Mary Ainsworth, also stressed the
importance of social relationships for development. Blatz proposed that the need for security was a normal part of
personality, as was the use of others as a secure base.[62] Observers from the 1940s onward focused on anxiety
displayed by infants and toddlers threatened with separation from a familiar caregiver.[63] [64]
Another theory prevalent at the time of Bowlby's development of attachment theory was "dependency". This
proposed that infants were dependent on adult caregivers but outgrew it in the course of early childhood; attachment
behaviour in older children would thus be seen as regressive. Attachment theory assumes older children and adults
retain attachment behaviour, displaying it in stressful situations. Indeed, a secure attachment is associated with
independent exploratory behaviour rather than dependence.[65] Bowlby developed attachment theory as a
consequence of his dissatisfaction with existing theories of early relationships.[1]
166
Attachment theory
167
The early thinking of the object relations school of psychoanalysis, particularly Melanie Klein, influenced Bowlby.
However, he profoundly disagreed with the prevalent psychoanalytic belief that infants' responses relate to their
internal fantasy life rather than real-life events. As Bowlby formulated his concepts, he was influenced by case
studies on disturbed and delinquent children, such as those of William Goldfarb published in 1943 and 1945.[66] [67]
Bowlby's contemporary Ren Spitz observed
separated children's grief, proposing that
"psychotoxic" results were brought about by
inappropriate experiences of early care.[68] [69] A
strong influence was the work of social worker
and psychoanalyst James Robertson who filmed
the effects of separation on children in hospital.
He and Bowlby collaborated in making the 1952
documentary film A Two-Year Old Goes to the
Hospital which was instrumental in a campaign
to alter hospital restrictions on visits by
parents.[70]
Prayer time in the Five Points House of Industry residential nursery, 1888.
The maternal deprivation hypothesis published in 1951 caused a revolution in
the use of residential nurseries.
In his 1951 monograph for the World Health

Organisation, Maternal Care and Mental Health,
Bowlby put forward the hypothesis that "the infant and young child should experience a warm, intimate, and
continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and
enjoyment", the lack of which may have significant and irreversible mental health consequences. This was also
published as Child Care and the Growth of Love for public consumption. The central proposition was influential but
highly controversial.[71] At the time there was limited empirical data and no comprehensive theory to account for
such a conclusion.[72] Nevertheless, Bowlby's theory sparked considerable interest in the nature of early
relationships, giving a strong impetus to, (in the words of Mary Ainsworth), a "great body of research" in an
extremely difficult, complex area.[71] Bowlby's work (and Robertson's films) caused a virtual revolution in hospital
visiting by parents, hospital provision for children's play, educational and social needs and the use of residential
nurseries. Over time, orphanages were abandoned in favour of foster care or family-style homes in most developed
countries.[73]
Formulation of the theory

Following the publication of Maternal Care and Mental Health, Bowlby sought new understanding from the fields
of evolutionary biology, ethology, developmental psychology, cognitive science and control systems theory. He
formulated the innovative proposition that mechanisms underlying an infant's emotional tie to the
caregiver(s)emerged as a result of evolutionary pressure.[1] He set out to develop a theory of motivation and
behaviour control built on science rather than Freud's psychic energy model.[5] Bowlby argued that with attachment
theory he had made good the "deficiencies of the data and the lack of theory to link alleged cause and effect" of
Maternal Care and Mental Health.[74]
Attachment theory
168
The formal origin of the theory began with the publication of two
papers in 1958, the first being Bowlby's "The Nature of the Child's Tie
to his Mother", in which the precursory concepts of "attachment" were
introduced. The second was Harry Harlow's "The Nature of Love". The
latter was based on experiments which showed that infant rhesus
monkeys appeared to form an affectional bond with soft, cloth
surrogate mothers that offered no food but not with wire surrogate
mothers that provided a food source but were less pleasant to touch.[25]
[75] [76]
Bowlby followed up his first paper with two more; "Separation
Infant exploration is greater when the caregiver is
Anxiety" (1960a), and "Grief and Mourning in Infancy and Early
present; with the caregiver present, the infant's
Childhood"
(1960b).[77] [78] At the same time, Bowlby's colleague
attachment system is relaxed and he is free to
Mary Ainsworth, with Bowlby's ethological theories in mind, was
explore.
completing her extensive observational studies on the nature of infant
[5]
attachments in Uganda. Attachment theory was finally presented in 1969 in Attachment, the first volume of the
Attachment and Loss trilogy. The second and third volumes, Separation: Anxiety and Anger and Loss: Sadness and
Depression followed in 1972 and 1980 respectively. Attachment was revised in 1982 to incorporate later research.
Attachment theory came at a time when women were asserting their right to equality and independence, giving
mothers new cause for anxiety. Attachment theory itself is not gender specific but in Western society it was largely
mothers who bore responsibility for early child care. Thus lack of proper nurturing of children was blamed on
mothers despite societal organisation that left them overburdened. Opposition to attachment theory coalesced around
this issue.[79] Feminists had already criticised the assumption that anatomy is destiny which they saw as implicit in
the maternal deprivation hypothesis.[80]
Ethology
Bowlby's attention was first drawn to ethology when he read Konrad Lorenz's 1952 publication in draft form
(although Lorenz had published earlier work).[81] Other important influences were ethologists Nikolaas Tinbergen
and Robert Hinde.[82] Bowlby subsequently collaborated with Hinde.[83] In 1953 Bowlby stated "the time is ripe for
a unification of psychoanalytic concepts with those of ethology, and to pursue the rich vein of research which this
union suggests".[84] Konrad Lorenz had examined the phenomenon of "imprinting", a behaviour characteristic of
some birds and mammals which involves rapid learning of recognition by the young, of a conspecific or comparable
object. After recognition comes a tendency to follow.
The learning is possible only within a limited age range known as a
critical period. Bowlby's concepts included the idea that attachment
involved learning from experience during a limited age period,
influenced by adult behaviour. He did not apply the imprinting concept
in its entirety to human attachment. However, he considered that
attachment behaviour was best explained as instinctive, combined with
the effect of experience, stressing the readiness the child brings to
social interactions.[85] Over time it became apparent there were more
differences than similarities between attachment theory and imprinting
so the analogy was dropped.[8]
This bottle-fed young moose has developed an

attachment to its carer.
Ethologists expressed concern about the adequacy of some research on which attachment theory was based,
particularly the generalisation to humans from animal studies.[86] [87] Schur, discussing Bowlby's use of ethological
concepts (pre-1960) commented that concepts used in attachment theory had not kept up with changes in ethology
itself.[88] Ethologists and others writing in the 1960s and 1970s questioned and expanded the types of behaviour used
as indications of attachment.[89] Observational studies of young children in natural settings provided other
Attachment theory
behaviours that might indicate attachment; for example, staying within a predictable distance of the mother without
effort on her part and picking up small objects, bringing them to the mother but not to others.[90] Although
ethologists tended to be in agreement with Bowlby, they pressed for more data, objecting to psychologists writing as
if there was an "entity which is 'attachment', existing over and above the observable measures."[91] Robert Hinde
considered "attachment behaviour system" to be an appropriate term which did not offer the same problems "because
it refers to postulated control systems that determine the relations between different kinds of behaviour."[92]
Psychoanalysis
Psychoanalytic concepts influenced Bowlby's view of attachment, in
particular, the observations by Anna Freud and Dorothy Burlingham of
young children separated from familiar caregivers during World War
II.[93] However, Bowlby rejected psychoanalytical explanations for
early infant bonds including "drive theory" in which the motivation for
attachment derives from gratification of hunger and libidinal drives. He
called this the "cupboard-love" theory of relationships. In his view it
failed to see attachment as a psychological bond in its own right rather
than an instinct derived from feeding or sexuality.[94] Based on ideas of
Evacuation of smiling Japanese school children in
primary attachment and neo-Darwinism, Bowlby identified what he
World War II from the book Road to Catastrophe
saw as fundamental flaws in psychoanalysis. Firstly the overemphasis
of internal dangers rather than external threat. Secondly the view of the
development of personality via linear "phases" with "regression" to fixed points accounting for psychological
distress. Instead he posited that several lines of development were possible, the outcome of which depended on the
interaction between the organism and the environment. In attachment this would mean that although a developing
child has a propensity to form attachments, the nature of those attachments depends on the environment to which the
child is exposed.[95]
From early in the development of attachment theory there was criticism of the theory's lack of congruence with
various branches of psychoanalysis. Bowlby's decisions left him open to criticism from well-established thinkers
working on similar problems.[96] [97] [98] Bowlby was effectively ostracized from the psychoanalytic community.[8]
Internal working model
Bowlby adopted the important concept of the internal working model of social relationships from the work of the
philosopher Kenneth Craik. Craik had noted the adaptiveness of the ability of thought to predict events. He stressed
the survival value of and natural selection for this ability. According to Craik, prediction occurs when a "small-scale
model" consisting of brain events is used to represent not only the external environment, but the individual's own
possible actions. This model allows a person to try out alternatives mentally, using knowledge of the past in
responding to the present and future. At about the same time Bowlby was applying Craik's ideas to attachment, other
psychologists were applying these concepts to adult perception and cognition.[99]
Cybernetics
The theory of visible systems (cybernetics), developing during the 1930s and '40s, influenced Bowlby's thinking.[100]
The young child's need for proximity to the attachment figure was seen as balancing homeostatically with the need
for exploration. (Bowlby compared this process to physiological homeostasis whereby, for example, blood pressure
is kept within limits). The actual distance maintained by the child would vary as the balance of needs changed. For
example, the approach of a stranger, or an injury, would cause the child exploring at a distance to seek proximity.
The child's goal is not an object (the caregiver) but a state; maintenance of the desired distance from the caregiver
depending on circumstances.[1]
169
Attachment theory
Bowlby's reliance on Piaget's theory of cognitive development gave rise to questions about object permanence (the
ability to remember an object that is temporarily absent) in early attachment behaviours. An infant's ability to
discriminate strangers and react to the mother's absence seemed to occur months earlier than Piaget suggested would
be cognitively possible.[101] More recently, it has been noted that the understanding of mental representation has
advanced so much since Bowlby's day that present views can be more specific than those of Bowlby's time.[102]
Behaviourism
In 1969, Gerwitz discussed how mother and child could provide each other with positive reinforcement experiences
through their mutual attention, thereby learning to stay close together. This explanation would make it unnecessary
to posit innate human characteristics fostering attachment.[103] Learning theory, (behaviorism), saw attachment as a
remnant of dependency with the quality of attachment being merely a response to the caregiver's cues. Behaviourists
saw behaviours like crying as a random activity meaning nothing until reinforced by a caregiver's response. To
behaviourists, frequent responses would result in more crying. To attachment theorists, crying is an inborn
attachment behaviour to which the caregiver must respond if the infant is to develop emotional security.
Conscientious responses produce security which enhances autonomy and results in less crying. Ainsworth's research
in Baltimore supported the attachment theorists' view.[104]
Behaviourists generally disagree with this interpretation. Though they use a different analysis scale, they maintain
that behaviours like separation protest in infants result mainly from operant learning experiences. When a mother is
instructed to ignore crying and respond only to play behaviour, the baby ceases to protest and engages in play
behaviour. The "separation anxiety" resulting from such interactions is seen as learned behaviour, resulting from
misplaced contingencies. Such misplaced contingencies may represent the ambivalence on the part of the parent,
which is then is played out in the operant interaction.[105] Behaviourists see attachment more as a systems
phenomena then a biological predisposition. Patterson's group has shown that in uncertain environments the lack of
contingent relationships can account for problems in attachment and the sensitivity to contingencies.[106] In the last
decade, behaviour analysts have constructed models of attachment based on the importance of contingent
relationships. These behaviour analytic models have received some support from research,[107] and meta-analytic
reviews.[108]
Developments
As the formulation of attachment theory progressed, there was criticism of the empirical support for the theory.
Possible alternative explanations for results of empirical research were proposed.[109] Some of Bowlby's
interpretations of James Robertson's data were rejected by the researcher when he reported data from 13 young
children cared for in ideal rather than institutional circumstances on separation from their mothers.[110] In the second
volume of the trilogy, Separation, Bowlby acknowledged Robertson's study had caused him to modify his views on
the traumatic consequences of separation in which insufficient weight had been given to the influence of skilled care
from a familiar substitute.[111] In 1984 Skuse based criticism on the work of Anna Freud with children from
Theresienstadt who had apparently developed relatively normally despite serious deprivation in their early years. He
concluded there was an excellent prognosis for children with this background, unless there were biological or genetic
risk factors.[112]
Bowlby's arguments that even very young babies were social creatures and primary actors in creating relationships
with parents took some time to be accepted. So did Ainsworth's emphasis on the importance and primacy of maternal
attunement for psychological development (a point also argued by Donald Winnicott). In the 1970s Daniel Stern
undertook research on the concept of attunement between very young infants and caregivers, using micro-analysis of
video evidence. This added significantly to the understanding of the complexity of infant/caregiver interactions as an
integral part of a baby's emotional and social development.[113]
170
Attachment theory
171
In the 1970s, problems with viewing attachment as a trait (stable characteristic of an individual) rather than as a type
of behaviour with organising functions and outcomes, led some authors to the conclusion that attachment behaviours
were best understood in terms of their functions in the child's life.[114] This way of thinking saw the secure base
concept as central to attachment theory's, logic, coherence and status as an organizational construct.[115] Following
this argument, the assumption that attachment is expressed identically in all humans cross-culturally was
examined.[116] The research showed that though there were cultural differences, the three basic patterns, secure,
avoidant and ambivalent, can be found in every culture in which studies have been undertaken, even where
communal sleeping arrangements are the norm.
Selection of the secure pattern is found in the majority of children
across cultures studied. This follows logically from the fact that
attachment theory provides for infants to adapt to changes in the
environment, selecting optimal behavioural strategies.[117] How
attachment is expressed shows cultural variations which need to be
ascertained before studies can be undertaken; for example Gusii infants
are greeted with a handshake rather than a hug. Securely attached Gusii
infants anticipate and seek this contact. There are also differences in
the distribution of insecure patterns based on cultural differences in
child-rearing practices.[117]
Research indicates that attachment pattern

distributions are consistent across cultures,
although the manner in which attachment is
expressed may differ.
The biggest challenge to the notion of the universality of attachment

theory came from studies conducted in Japan where the concept of
amae plays a prominent role in describing family relationships.
Arguments revolved around the appropriateness of the use of the Strange Situation procedure where amae is
practiced. Ultimately research tended to confirm the universality hypothesis of attachment theory.[117] Most recently
a 2007 study conducted in Sapporo in Japan found attachment distributions consistent with global norms using the
six-year Main and Cassidy scoring system for attachment classification.[118] [119]
Critics in the 1990s such as J. R. Harris, Steven Pinker and Jerome Kagan were generally concerned with the concept
of infant determinism (nature versus nurture), stressing the effects of later experience on personality.[120] [121] [122]
Building on the work on temperament of Stella Chess, Kagan rejected almost every assumption on which attachment
theory etiology was based. He argued that heredity was far more important than the transient effects of early
environment. For example a child with an inherently difficult temperament would not elicit sensitive behavioural
responses from a caregiver. The debate spawned considerable research and analysis of data from the growing
number of longitudinal studies.[123] Subsequent research has not borne out Kagan's argument, broadly demonstrating
that it is the caregiver's behaviours that form the child's attachment style, although how this style is expressed may
differ with temperament.[124] Harris and Pinker put forward the notion that the influence of parents had been much
exaggerated, arguing that socialisation took place primarily in peer groups. H. Rudolph Schaffer concluded that
parents and peers had different functions, fulfilling distinctive roles in children's development.[125]
Recent developments
Whereas Bowlby was inspired by Piaget's insights into children's thinking, current attachment scholars utilise
insights from contemporary literature on implicit knowledge, theory of mind, autobiographical memory and social
representation.[126] Psychoanalyst/psychologists Peter Fonagy and Mary Target have attempted to bring attachment
theory and psychoanalysis into a closer relationship through cognitive science as mentalization.[100] Mentalization,
or theory of mind, is the capacity of human beings to guess with some accuracy what thoughts, emotions and
intentions lie behind behaviours as subtle as facial expression.[127] This connection between theory of mind and the
internal working model may open new areas of study, leading to alterations in attachment theory.[128] Since the late
1980s, there has been a developing rapprochement between attachment theory and psychoanalysis, based on
Attachment theory
172
common ground as elaborated by attachment theorists and researchers, and a change in what psychoanalysts consider
to be central to psychoanalysis. Object relations models which emphasise the autonomous need for a relationship
have become dominant and are linked to a growing recognition within psychoanalysis of the importance of infant
development in the context of relationships and internalised representations. Psychoanalysis has recognised the
formative nature of a childs early environment including the issue of childhood trauma. A psychoanalytically based
exploration of the attachment system and an accompanying clinical approach has emerged together with a
recognition of the need for measurement of outcomes of interventions.[129]
One focus of attachment research has been the difficulties of children
whose attachment history was poor, including those with extensive
non-parental child care experiences. Concern with the effects of child
care was intense during the so-called "day care wars" of the late 20th
century, during which some authors stressed the deleterious effects of
day care.[130] As a result of this controversy, training of child care
professionals has come to stress attachment issues, including the need
for relationship-building by the assignment of a child to a specific
carer. Although only high-quality child care settings are likely to
provide this, more infants in child care receive attachment-friendly
care than in the past.[131]
Another significant area of research and development has been the
connection between problematic attachment patterns, particularly
disorganized attachment, and the risk of later psychopathology.[126] A
third has been the effect on development of children having little or no
opportunity to form attachments at all in their early years. A natural
experiment permitted extensive study of attachment issues as
researchers followed thousands of Romanian orphans adopted into
Authors considering attachment in non-western
Western families after the end of the Nicolae Ceauescu regime. The
cultures have noted the connection of attachment
English and Romanian Adoptees Study Team, led by Michael Rutter,
theory with Western family and child care
followed some of the children into their teens, attempting to unravel
patterns characteristic of Bowlby's time.
the effects of poor attachment, adoption, new relationships, physical
problems and medical issues associated with their early lives. Studies
of these adoptees, whose initial conditions were shocking, yielded reason for optimism as many of the children
developed quite well. Researchers noted that separation from familiar people is only one of many factors that help to
determine the quality of development.[132] Although higher rates of atypical insecure attachment patterns were found
compared to native-born or early-adopted samples, 70% of later-adopted children exhibited no marked or severe
attachment disorder behaviours.[40]
Authors considering attachment in non-Western cultures have noted the connection of attachment theory with
Western family and child care patterns characteristic of Bowlby's time.[133] As children's experience of care changes,
so may attachment-related experiences. For example, changes in attitudes toward female sexuality have greatly
increased the numbers of children living with their never-married mothers or being cared for outside the home while
the mothers work. This social change has made it more difficult for childless people to adopt infants in their own
countries. There has been an increase in the number of older-child adoptions and adoptions from third-world sources
in first-world countries. Adoptions and births to same-sex couples have increased in number and gained legal
protection, compared to their status in Bowlby's time.[134] Issues have been raised to the effect that the dyadic model
characteristic of attachment theory cannot address the complexity of real-life social experiences, as infants often
have multiple relationships within the family and in child care settings.[135] It is suggested these multiple
relationships influence one another reciprocally, at least within a family.[136]
Attachment theory
Principles of attachment theory have been used to explain adult social behaviours, including mating, social
dominance and hierarchical power structures, group coalitions, and negotiation of reciprocity and justice.[137] Those
explanations have been used to design parental care training, and have been particularly successful in the design of
child abuse prevention programmes.[138]
Biology of attachment
Attachment theory proposes that the quality of caregiving from at least the primary carer is key to attachment
security or insecurity.[123] In addition to longitudinal studies, there has been psychophysiological research on the
biology of attachment.[139] Research has begun to include behaviour genetics and temperament concepts.[124]
Generally temperament and attachment constitute separate developmental domains, but aspects of both contribute to
a range of interpersonal and intrapersonal developmental outcomes.[124] Some types of temperament may make some
individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years.[140] In
the absence of available and responsive caregivers it appears that some children are particularly vulnerable to
developing attachment disorders.[141]
In psychophysiological research on attachment, the two main areas studied have been autonomic responses, such as
heart rate or respiration, and the activity of the hypothalamic-pituitary-adrenal axis. Infants' physiological responses
have been measured during the Strange Situation procedure looking at individual differences in infant temperament
and the extent to which attachment acts as a moderator. There is some evidence that the quality of caregiving shapes
the development of the neurological systems which regulate stress.[139]
Another issue is the role of inherited genetic factors in shaping attachments: for example one type of polymorphism
of the DRD2 dopamine receptor gene has been linked to anxious attachment and another in the 5-HT2A serotonin
receptor gene with avoidant attachment.[142] This suggests that the influence of maternal care on attachment security
is not the same for all children. One theoretical basis for this is that it makes biological sense for children to vary in
their susceptibility to rearing influence.[130]
Practical applications
As a theory of socioemotional development, attachment theory has implications and practical applications in social
policy, decisions about the care and welfare of children and mental health.
Child care policies

Social policies concerning the care of children were the driving force in Bowlby's development of attachment theory.
The difficulty lies in applying attachment concepts to policy and practice.[143] This is because the theory emphasises
the importance of continuity and sensitivity in caregiving relationships rather than a behavioural approach on
stimulation or reinforcement of child behaviours.[144] In 2008 C.H. Zeanah and colleagues stated, "Supporting early
child-parent relationships is an increasingly prominent goal of mental health practitioners, community based service
providers and policy makers... Attachment theory and research have generated important findings concerning early
child development and spurred the creation of programs to support early child-parent relationships".[10]
Historically, attachment theory had significant policy implications for hospitalised or institutionalised children, and
those in poor quality daycare.[145] Controversy remains over whether non-maternal care, particularly in group
settings, has deleterious effects on social development. It is plain from research that poor quality care carries risks
but that those who experience good quality alternative care cope well although it is difficult to provide good quality,
individualised care in group settings.[143]
Attachment theory has implications in residence and contact disputes,[145] and applications by foster parents to adopt
foster children. In the past, particularly in North America, the main theoretical framework was psychoanalysis.
Increasingly attachment theory has replaced it, thus focusing on the quality and continuity of caregiver relationships
173
Attachment theory
rather than economic well-being or automatic precedence of any one party, such as the biological mother. However,
arguments tend to focus on whether children are "attached" or "bonded" to the disputing adults rather than the quality
of attachments. Rutter noted that in the UK, since 1980, family courts have shifted considerably to recognize the
complications of attachment relationships.[144] Children tend to have security-providing relationships with both
parents and often grandparents or other relatives. Judgements need to take this into account along with the impact of
step-families. Attachment theory has been crucial in highlighting the importance of social relationships in dynamic
rather than fixed terms.[143]
Attachment theory can also inform decisions made in social work and court processes about foster care or other
placements. Considering the child's attachment needs can help determine the level of risk posed by placement
options.[146] Within adoption, the shift from "closed" to "open" adoptions and the importance of the search for
biological parents would be expected on the basis of attachment theory. Many researchers in the field were strongly
influenced by it.[143]
Clinical practice in children

Although attachment theory has become a major scientific theory of socioemotional development with one of the
broadest, deepest research lines in modern psychology, it has, until recently, been less used in clinical practice than
theories with far less empirical support.
This may be partly due to lack of attention paid to clinical application
by Bowlby himself and partly due to broader meanings of the word
'attachment' used amongst practitioners. It may also be partly due to the
mistaken association of attachment theory with the pseudoscientific
interventions misleadingly known as "attachment therapy".[147]
Prevention and treatment
In 1988, Bowlby published a series of lectures indicating how
attachment theory and research could be used in understanding and
treating child and family disorders. His focus for bringing about
change was the parents' internal working models, parenting behaviours
and the parents' relationship with the therapeutic intervenor.[148]
Ongoing research has led to a number of individual treatments and
prevention and intervention programmes.[148] They range from
individual therapy to public health programmes to interventions
designed for foster carers. For infants and younger children, the focus
is on increasing the responsiveness and sensitivity of the caregiver, or
In the early months of life, babies will direct
if that is not possible, placing the child with a different caregiver.[149]
attachment behaviours towards anyone in the
[150]
vicinity. As attachment develops, so does
An assessment of the attachment status or caregiving responses of
age-appropriate stranger wariness.
the caregiver is invariably included, as attachment is a two-way
process involving attachment behaviour and caregiver response. Some
programmes are aimed at foster carers because the attachment behaviours of infants or children with attachment
difficulties often do not elicit appropriate caregiver responses. Modern prevention and intervention programmes are
mostly in the process of being evaluated.[151]
174
Attachment theory
Reactive attachment disorder and attachment disorder
One atypical attachment pattern is considered to be an actual disorder, known as reactive attachment disorder or
RAD, which is a recognized psychiatric diagnosis (ICD-10 F94.1/2 and DSM-IV-TR 313.89). The essential feature
of reactive attachment disorder is markedly disturbed and developmentally inappropriate social relatedness in most
contexts that begins before age five years, associated with gross pathological care. There are two subtypes, one
reflecting a disinhibited attachment pattern, the other an inhibited pattern. RAD is not a description of insecure
attachment styles, however problematic those styles may be; instead, it denotes a lack of age-appropriate attachment
behaviours that amounts to a clinical disorder.[152] Although the term "reactive attachment disorder" is now
popularly applied to perceived behavioural difficulties that fall outside the DSM or ICD criteria, particularly on the
Web and in connection with the pseudo-scientific attachment therapy, "true" RAD is thought to be rare.[153]
"Attachment disorder" is an ambiguous term, which may be used to refer to reactive attachment disorder or to the
more problematical insecure attachment styles (although none of these are clinical disorders). It may also be used to
refer to proposed new classification systems put forward by theorists in the field,[154] and is used within attachment
therapy as a form of unvalidated diagnosis.[153] One of the proposed new classifications, "secure base distortion" has
been found to be associated with caregiver traumatization.[155]
Clinical practice in adults and families

As attachment theory offers a broad, far-reaching view of human functioning, it can enrich a therapist's
understanding of patients and the therapeutic relationship rather than dictate a particular form of treatment.[156] Some
forms of psychoanalysis-based therapy for adultswithin relational psychoanalysis and other approachesalso
incorporate attachment theory and patterns.[156] [157] In the first decade of the 21st century, key concepts of
attachment were incorporated into existing models of behavioural couple therapy, multidimensional family therapy
and couple and family therapy. Specifically attachment-centred interventions have been developed, such as
attachment-based family therapy and emotionally focused therapy.[158] [159]
Attachment theory and research laid the foundation for the development of the understanding of "mentalization" or
reflective functioning and its presence, absence or distortion in psychopathology. The dynamics of an individual's
attachment organization and their capacity for mentalization can play a crucial role in the capacity to be helped by
treatment.[156] [160]
Notes
[1] Cassidy J (1999). "The Nature of a Child's Ties". In Cassidy J, Shaver PR. Handbook of Attachment: Theory, Research and Clinical
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[3] Prior and Glaser p. 17.
[4] Simpson JA (1999). "Attachment Theory in Modern Evolutionary Perspective". In Cassidy J, Shaver PR. Handbook of Attachment: Theory,
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[5] Bretherton I (1992). "The Origins of Attachment Theory: John Bowlby and Mary Ainsworth". Developmental Psychology 28 (5): 759.
doi:10.1037/0012-1649.28.5.759.
[6] N.J. Salkind: Child Development 2002, page 34
[7] Hazan C, Shaver PR (March 1987). "Romantic love conceptualized as an attachment process". Journal of Personality and Social Psychology
52 (3): 51124. doi:10.1037/0022-3514.52.3.511. PMID3572722.
[8] Rutter, Michael (1995). "Clinical Implications of Attachment Concepts: Retrospect and Prospect". Journal of Child Psychology & Psychiatry
36 (4): 54971. doi:10.1111/j.1469-7610.1995.tb02314.x. PMID7650083.
[9] Schaffer R (2007). Introducing Child Psychology. Oxford: Blackwell. pp.83121. ISBN0-631-21628-6.
[10] Berlin L, Zeanah CH, Lieberman AF (2008). "Prevention and Intervention Programs for Supporting Early Attachment Security". In Cassidy
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[11] Bretherton I (1992). The Origins of Attachment Theory: John Bowlby and Mary Ainsworth. "[Bowlby] begins by noting that organisms at
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175
Attachment theory
patterns" to complex plan hierarchies with subgoals and strong learning components. In the most complex organisms, instinctive behaviors
may be "goal-corrected" with continual on-course adjustments (such as a bird of prey adjusting its flight to the movements of the prey). The
concept of cybernetically controlled behavioral systems organized as plan hierarchies (Miller, Galanter, and Pribram, 1960) thus came to
replace Freud's concept of drive and instinct. Such systems regulate behaviors in ways that need not be rigidly innate, butdepending on the
organismcan adapt in greater or lesser degrees to changes in environmental circumstances, provided that these do not deviate too much from
the organism's environment of evolutionary adaptedness. Such flexible organisms pay a price, however, because adaptable behavioral systems
can more easily be subverted from their optimal path of development. For humans, Bowlby speculates, the environment of evolutionary
adaptedness probably resembles that of present-day hunter-gatherer societies."
[13] Bowlby (1969) p. 365.
[14] Holmes p. 69.
[15] Bowlby (1969) 2nd ed. pp. 30405.
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[22] Karen p. 97.
[23] Prior and Glaser pp. 1920.
[24] Bowlby (1969) p. 300.
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[28] Mercer pp.3940.
[29] Bowlby J (1973). Separation: Anger and Anxiety. Attachment and loss. Vol. 2. London: Hogarth. ISBN0-7126-6621-4.
[30] Bowlby (1969) pp. 41421.
[31] Bowlby (1969) pp. 394395.
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10727. "sometimes referred to by Bowlby's colleagues as "Ali Bowlby and the Forty Thieves""
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other than man can be used only to suggest hypotheses that may be worth applying to man for testing by critical observations. In the absence
of critical evidence derived from observing man such hypotheses are no more than intelligent guesses. There is a danger in human ethology...
that interesting, but untested, hypotheses may gain the status of accepted theory. [One author] has coined the term 'ethologism' as a label for
the present vogue [in 1970]... for uncritically invoking the findings from ethological studies of other species as necessary and sufficient
explanations... Theory based on superficial analogies between species has always impeded biological understanding... We conclude that a
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impact of learning and the great intricacy of the interaction between mother and litter"...(and applies)..."to human behavior an instinct concept
which neglects the factor of development and learning far beyond even the position taken by Lorenz [the ethological theorist] in his early
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[99] Johnson-Laird PN (1983). Mental models. Cambridge, MA: Harvard University Press. pp.17987. ISBN0-674-56881-8.
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[104] Karen pp. 16673.
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[110] Robertson J, Robertson J (1971). "Young children in brief separation. A fresh look". Psychoanalytic Study of the Child 26: 264315.
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the context from which it was derived. He asserts that these are the usual responses of young children to separation from the mother regardless
of circumstance..."; however, of the 13 separated children who received good care, none showed protest and despair, but "coped with
separation from the mother when cared for in conditions from which the adverse factors which complicate institutional studies were absent"
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[125] Schaffer HR (2004). Introducing Child Psychology. Oxford: Blackwell. p.113. ISBN978-0-631-21627-8.
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[128] Mercer pp. 16568.
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[130] Belsky J, Rovine MJ (February 1988). "Nonmaternal care in the first year of life and the security of infant-parent attachment". Child
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[131] Mercer pp. 16063.
[132] Rutter M (Jan/February 2002). "Nature, nurture, and development: From evangelism through science toward policy and practice". Child
Development 73 (1): 121. doi:10.1111/1467-8624.00388. PMID14717240.
[133] Miyake K, Chen SJ (1985). "Infant temperament, mother's mode of interaction, and attachment in Japan: An interim report". In Bretherton
I, Waters E. Growing Points of Attachment Theory and Research: Monographs of the Society for Research in Child Development. 50 (12,
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[134] Mercer pp. 15256.
[135] McHale JP (2007). "When infants grow up in multiperson relationship systems". Infant Mental Health Journal 28 (4): 37092.
doi:10.1002/imhj.20142.
[136] Zhang X, Chen C (2010). "Reciprocal Influences between Parents' Perceptions of Mother-Child and Father-Child Relationships: A
Short-Term Longitudinal Study in Chinese Preschoolers". The Journal of Genetic Psychology 171 (1): 2234.
doi:10.1080/00221320903300387. PMID20333893.
[137] Bugental DB (2000). "Acquisition of the Algorithms of Social Life: A Domain-Based Approach". Psychological Bulletin 126 (2):
178219. doi:10.1037/0033-2909.126.2.187. PMID10748640.
[138] Bugental DB, Ellerson PC, Rainey B, Lin EK, Kokotovic A (2002). "A Cognitive Approach to Child Abuse Prevention". Journal of Family
Psychology 16 (3): 24358. doi:10.1037/0893-3200.16.3.243. PMID12238408.
[139] Fox NA, Hane AA (2008). "Studying the Biology of Human Attachment". In Cassidy J, Shaver PR. Handbook of Attachment: Theory,
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[140] Marshall PJ, Fox NA (2005). "Relationship between behavioral reactivity at 4 months and attachment classification at 14 months in a
selected sample". Infant Behavior and Development 28 (4): 492502. doi:10.1016/j.infbeh.2005.06.002.
[142] Gillath O, Shaver PR, Baek JM, Chun DS (October 2008). "Genetic correlates of adult attachment style". Personality and Social
Psychology Bulletin 34 (10): 1396405. doi:10.1177/0146167208321484. PMID18687882.
[143] Rutter M (2008). "Implications of Attachment Theory and Research for Child Care Policies". In Cassidy J, Shaver PR. Handbook of
[144] Rutter M, O'Connor TG (1999). "Implications of Attachment Theory for Child Care Policies". In Cassidy J, Shaver PR. Handbook of
Attachment: Theory, Research and Clinical Applications. New York: Guilford Press. pp.82344. ISBN1572300876.
[145] Karen pp. 25258.
[146] Goldsmith DF, Oppenheim D, Wanlass J (2004). "Separation and Reunification: Using Attachment Theory and Research to Inform
Decisions Affecting the Placements of Children in Foster Care" (http:/ / www. zerotothree. org/ site/ DocServer/ AttachmentandFosterCare.
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References
Ainsworth MD (1967). Infancy in Uganda. Baltimore: Johns Hopkins. ISBN978-0-8018-0010-8.
Bowlby J (1953). Child Care and the Growth of Love. London: Penguin Books.
ISBN978-0-14-020271-7.(version of WHO publication Maternal Care and Mental Health published for sale to
the general public)
Bowlby J (1969). Attachment. Attachment and Loss. Vol. I. London: Hogarth. (page numbers refer to Pelican
edition 1971)
Bowlby J (1999) [1982]. Attachment. Attachment and Loss Vol. I (2nd ed.). New York: Basic Books.
ISBN0465005438 (pbk). OCLC11442968. LCCN00-266879; NLM 8412414.
Bowlby J (1979). The Making and Breaking of Affectional Bonds. London: Tavistock Publications.
ISBN978-0-422-76860-3.
Bowlby J (1988). A Secure Base: Clinical Applications of Attachment Theory. London: Routledge.
ISBN0415006406 (pbk).
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Craik K (1943). The Nature of Explanation. Cambridge: Cambridge University Press. ISBN978-0-521-09445-0.
ISSNB0007J4QKE.
Holmes J (1993). John Bowlby & Attachment Theory. Makers of modern psychotherapy. London: Routledge.
ISBN0-415-07729-X.
Karen R (1998). Becoming Attached: First Relationships and How They Shape Our Capacity to Love. Oxford and
New York: Oxford University Press. ISBN0-19-511501-5.
Mercer J (2006). Understanding Attachment: Parenting, child care, and emotional development. Westport, CT:
Praeger Publishers. ISBN0-275-98217-3. OCLC61115448. LCCN2005-19272.
Prior V, Glaser D (2006). Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice.
Child and Adolescent Mental Health, RCPRTU. London and Philadelphia: Jessica Kingsley Publishers.
ISBN9781843102458 (pbk).
Tinbergen N (1951). The study of instinct. Oxford: Oxford University Press. ISBN978-0-19-857722-5.
Further reading
Grossmann KE, Waters E (2005). Attachment from infancy to adulthood: The major longitudinal studies. New
York: Guilford Press. ISBN978-1-59385-381-5.
Barrett H (2006). Attachment and the perils of parenting: A commentary and a critique. London: National Family
and Parenting Institute. ISBN978-1-903615-42-3.
Crittenden PM (2008). Raising parents: attachment, parenting and child safety. Devon and Oregon: Willan
Publishing. ISBN978-1-84392-498-2.
Bell DC (2010). The Dynamics of Connection: How Evolution and Biology Create Caregiving and Attachment.
Lanham MD: Lexington. ISBN978-0-7391-4352-0.
Miller WB, Rodgers JL (2001). The Ontogeny of Human Bonding Sysytems: Evolutionary Origins, Neural Bases,
and Psychological Manifestations. New York: Springer. ISBN0-7923-7478-9.
Goodall J (1971). In the Shadow of Man. Houghton Mifflin Co.. ISBN978-0-618-05676-7.
Attachment & Human Development. London: Routledge. ISSN14692988.
Infant Mental Health Journal. Michigan Association for Infant Mental Health, WAIMH. ISSN10970355.
Van der Horst FCP (2011). John Bowlby - From Psychoanalysis to Ethology. Unraveling the Roots of Attachment
Theory. Oxford: Wiley-Blackwell. ISBN978-0-470-68364-4.
Juffer F, Bakermans-Kranenburg MJ, Van IJzendoorn MH (2008). Promoting positive parenting: An
attachment-based intervention. New York/London: Taylor and Francis Group. ISBN13: 978-0-8058-6352-9.
External links
Attachment Theory and Research at Stony Brook (http://www.psychology.sunysb.edu/attachment/index.
html)
The Attachment Theory Website (http://www.richardatkins.co.uk/atws)
Richard Karen: 'Becoming Attached (http://www.psychology.sunysb.edu/attachment/online/karen.pdf)'. The
Atlantic Monthly February 1990.
Review of Richard Karen. Becoming Attached: First Relationships and How They Shape Our Capacity to Love
(http://www.isi.edu/~lerman/etc/BecomingAttached.pdf)
Rene Spitz's film "Psychogenic Disease in Infancy" (1957) (http://www.archive.org/details/PsychogenicD)
The Parental Deficit Website (http://www.parentaldeficit.it/default.aspx)
181
182
Newborn humans infants cannot survive without a caregiver to
provide food and protection, and will not thrive without other
types of support as well. While infants have relatively few
inborn behaviorssuch as crying, rooting, and suckingthey
also come with many behavioral systems ready to be activated
through interaction with another person. In their first year babies
brains double in volume and their experiences will be hardwired
in as a foundation on which to build their lives. The deep bond
which babies form with their primary caregiver is called
Attachment, the foundation on which all other close, long-term
relationships will be built. Parents can bond with their baby by
touching, cuddling, eye contact, listening, and facial expressions, etc.
Mother and child
Attachment theory studies and describes this first relationship; it's an interdisciplinary study that includes
developmental psychology and ethology (behavioral biology). Attachment is found in all mammals to some degree,
especially nonhuman primates. See discussion page.
Attachment in children is a theory of attachment between children and their caregivers specifically addressing the
behaviors and emotions that children direct toward familiar adults. It is primarily an evolutionary and ethological
theory postulating that infants seek proximity to a specified attachment figure in situations of distress or alarm for the
purpose of survival.[1]
Attachment in childhood can also be described as the considerable closeness a child feels to an authority figure. It
also describes the function of availability, which is the degree to which the authoritative figure is responsive to the
child's needs and shares communication with them. Childhood attachment can define characteristics that will shape
the childs sense of self and how they carry out relationships with others.[2]
Attachment theory has led to a new understanding of child development. Children develop different styles of
attachment based on experiences and interactions with their caregivers. Four different attachment styles or patterns
have been identified in children: secure attachment, anxious-ambivalent attachment, anxious-avoidant attachment,
and disorganized attachment. Attachment theory has become the dominant theory used today in the study of infant
and toddler behavior and in the fields of infant mental health, treatment of children, and related fields.
Attachment theory and children

Attachment theory (Bowlby 1969, 1973, 1980) is rooted in the ethological notion that a newborn child is biologically
programmed to seek proximity with caregivers, and this proximity-seeking behavior is naturally selected.[3] [4] [5]
Through repeated attempts to seek physical and emotional closeness with a caregiver and the responses the child
gets, the child develops an internal working model (IWM) of the self and others that reflects the response of the
caregiver to the child. According to Bowlby, attachment provides a secure base from which the child can explore the
environment, a haven of safety to which the child can return when he or she is afraid or fearful.
An infant may have different patterns of attachment with different care-givers. By around age five years, this
"crystalizes" into one pattern of attachment that is generally exhibited within most relationships.[6]
Attachment classification in children: The Strange Situation Protocol

The most common and empirically supported method for assessing attachment in infants (12months-20months) is
the Strange Situation Protocol, developed by Mary Ainsworth as a result of her careful in-depth observations of
infants with their mothers in Uganda(see below).[7] The Strange Situation Protocol is a research, not a diagnostic,
tool and the resulting attachment classifications are not 'clinical diagnoses.' While the procedure may be used to
supplement clinical impressions, the resulting classifications should not be confused with the clinically diagnosed
'Reactive Attachment Disorder (RAD).' The clinical concept of RAD differs in a number of fundamental ways from
the theory and research driven attachment classifications based on the Strange Situation Procedure. The idea that
insecure attachments are synonymous with RAD is, in fact, not accurate and leads to ambiguity when formally
discussing attachment theory as it has evolved in the research literature. This is not to suggest that the concept of
RAD is without merit, but rather that the clinical and research conceptualizations of insecure attachment and
attachment disorder are not synonymous.
The 'Strange Situation' is a laboratory procedure used to assess infant patterns of attachment to their caregiver. In the
procedure, the mother and infant are placed in an unfamiliar playroom equipped with toys while a researcher
observes/records the procedure through a one-way mirror. The procedure consists of eight sequential episodes in
which the child experiences both separation from and reunion with the mother as well as the presence of an
unfamiliar stranger.[7] The protocol is conducted in the following format unless modifications are otherwise noted by
a particular researcher:
Episode 1: Mother (or other familiar caregiver), Baby, Experimenter (30 seconds)
Episode 2: Mother, Baby (3 mins)
Episode 3: Mother, Baby, Stranger (3 mins or less)
Episode 4: Stranger, Baby (3 mins)
Episode 6: Baby Alone (3 mins or less)
Episode 7: Stranger, Baby (3 mins or less)
On the basis of predominately their reunion behaviours (although other behaviors are taken into account) in the
Strange Situation Paradigm (Ainsworth et al., 1978; see below), infants can be categorized into three 'organized'
attachment categories: Secure (Group B); Avoidant (Group A); and Anxious/Resistant (Group C). There are
subclassifications for each group (see below). A fourth category, termed Disorganized (D), can also be assigned to an
infant assessed in the Strange Situation although a primary 'organized' classification is always given for an infant
judged to be disorganized. Each of these groups reflects a different kind of attachment relationship with the mother.
A child may have a different type of attachment to each parent as well as to unrelated caregivers. Attachment style is
thus not so much a part of the child's thinking, but is characteristic of a specific relationship. However, after about
age four the child exhibits one primary consistent pattern of attachment in relationships.[8]
183
Attachment patterns
Secure attachment
A toddler who is securely attached to its parent (or other familiar caregiver) will explore freely while the caregiver is
present, typically engages with strangers, is often visibly upset when the caregiver departs, and is generally happy to
see the caregiver return. The extent of exploration and of distress are affected by the child's temperamental make-up
and by situational factors as well as by attachment status, however.
In the traditional Ainsworth et al. (1978) coding of the Strange Situation, secure infants are denoted as "Group B"
infants and they are further subclassified as B1, B2, B3, and B4.[7] Although these subgroupings refer to different
stylistic responses to the comings and goings of the caregiver, they were not given specific labels by Ainsworth and
colleagues, although their descriptive behaviors led others (including students of Ainsworth) to devise a relatively
'loose' terminology for these subgroups. B1's have been referred to as 'secure-reserved', B2's as 'secure-inhibited',
B3's as 'secure-balanced,' and B4's as 'secure-reactive.' In academic publications however, the classification of
infants (if subgroups are denoted) is typically simply "B1" or "B2" although more theoretical and review-oriented
papers surrounding attachment theory may use the above terminology.
Securely attached children are best able to explore when they have the knowledge of a secure base to return to in
times of need. When assistance is given, this bolsters the sense of security and also, assuming the parent's assistance
is helpful, educates the child in how to cope with the same problem in the future. Therefore, secure attachment can
be seen as the most adaptive attachment style. According to some psychological researchers, a child becomes
securely attached when the parent is available and able to meet the needs of the child in a responsive and appropriate
manner. Others have pointed out that there are also other determinants of the child's attachment, and that behavior of
the parent may in turn be influenced by the child's behavior.
Anxious-resistant insecure attachment

In general, a child with an anxious-resistant attachment style will typically explore little (in the Strange Situation)
and is often wary of strangers, even when the parent is present. When the mother departs, the child is often highly
distressed. The child is generally ambivalent when she returns. In the traditional Ainsworth et al. (1978) coding of
the Strange Situation, anxious-resistant infants are denoted as "Group C" infants and they are further subclassified
into C1 and C2 infants.[7] C1 infants are so judged when:
"...resistant behavior is particularly conspicuous. The mixture of seeking and yet resisting contact and interaction
has an unmistakeablely angry quality and indeed an angry tone may characterize behavior in the preseparation
episodes..."[7]
C2 infants are often seen as demonstrating 'passive' resistance. As Ainsworth et al. (1978) originally noted:
"Perhaps the most conspicuous characteristic of C2 infants is their passivity. Their exploratory behavior is limited
throughout the SS and their interactive behaviors are relatively lacking in active initiation. Nevertheless, in the
reunion episodes they obviously want proximity to and contact with their mothers, even though they tend to use
signalling rather than active approach, and protest against being put down rather than actively resisting release...In
general the C2 baby is not as conspicuously angry as the C1 baby."[7]
Anxious-avoidant insecure attachment

In general, a child with an anxious-avoidant attachment style will avoid or ignore the parent when he or she returns
(in the Strange Situation) - showing little overt indications of an emotional response. Often, the stranger will not be
treated much differently from the parent. In the traditional Ainsworth et al. (1978) coding of the Strange Situation,
anxious-avoidant infants are denoted as "Group A" infants and they are further subclassified into A1 and A2
infants.[7] A1 infants are so judged when there is:
184
"...conspicuous avoidance of the mother in the reunion episodes which is likely to consist of ignoring her altogether,
although there may be some pointed looking away, turning away, or moving away...If there is a greeting when the
mother enters, it tends to be a mere look or a smile...Either the baby does not approach his mother upon reunion, or
they approach in 'abortive' fashions with the baby going past the mother, or it tends to only occur after much
coaxing...If picked up, the baby shows little or no contact-maintaining behavior; he tends not to cuddle in; he looks
away and he may squirm to get down."[7]
A2 infants are often seen as demonstrating a mixture of both some avoidance and resistance. Often, though not
always, A2 infants are judged Disorganized (D). As Ainsworth et al. (1978) originally noted:
"...[the A2 infant] shows a mixed response to mother on reunion, with some tendency to greet and approach,
intermingled with a marked tendency to move or turn away from her, move past her, avert the gaze from her, or
ignore her...there may be moderate proximity-seeking, combined with strong proximity-avoiding...If picked up, the
baby may cling momentarily; if put down, he may protest or resist momentarily; but there is also a tendency to
squirm to be put down, to turn the face away when being held and other signs of mixed feelings [i.e.,
resistance/ambivalence]."[7]
Disorganized attachment
A fourth category termed disorganized attachment (Main & Solomon, 1990) was subsequently identified and
empiricized when a sizeable number of infants defied classification in terms of Ainsworth's original tripartite
classification scheme.[9] It can be conceptualized as the lack of a coherent 'organized' behavioral strategy for dealing
with the stresses (i.e., the strange room, the stranger, and the comings and goings of the caregiver) of the Strange
Situation Procedure. Evidence from Main et al. has suggested that children with disorganized attachment may
experience their caregivers as either frightening or frightened. A frightened caregiver is alarming to the child, who
uses social referencing techniques such as checking the adult's facial expression to ascertain whether a situation is
safe. A frightening caregiver is usually so via aggressive behaviors towards the child (either mild or direct
physical/sexual behaviors) and puts the child in a dilemma which Main and colleagues have called 'fear without
solution.' In other words, the caregiver is both the source of the child's alarm as well as the child's haven of safety.
Through parental behaviors that are frightening, the caregiver puts the child in an irresolvable paradox of
approach-avoidance. This paradox, in fact, may be one explanation for some of the 'stilling' and 'freezing' behaviors
observed in children judged to be disorganized. Human interactions are experienced as erratic, thus children cannot
form a coherent, organized interactive template. If the child uses the caregiver as a mirror to understand the self, the
disorganized child is looking into a mirror broken into a thousand pieces. It is more severe than learned helplessness
as it is the model of the self rather than of a situation. It is important to note that when a child is judged disorganized,
he or she is given a secondary best-fitting 'organized' (i.e., secure, ambivalent, avoidant) classification as well. This
reflects the fact that attachment disorganization is thought to be a breakdown of an inchoate organized attachment
strategy. The degree to which the organized strategy is fragmented however is often different in degree across infants
judged to receive a primary 'disorganized' classification.
There is a growing body of research on the links between abnormal parenting, disorganized attachment and risks for
later psychopathologies.[10] Abuse is associated with disorganized attachment.[11] [12] The disorganized style is a risk
factor for a range of psychological disorders although it is not in itself considered an attachment disorder under the
current classification.[13] [14]
185
Significance of patterns
Research based on data from longitudinal studies, such as the National Institute of Child Health and Human
Development Study of Early Child Care and the Minnesota Study of Risk and Adaption from Birth to Adulthood,
and from cross-sectional studies, consistently shows associations between early attachment classifications and peer
relationships as to both quantity and quality. Predictions are stronger for close relationships than for less intimate
ones. Secure children have more positive and fewer negative peer reactions and establish more and better
friendships. Insecure children tend to be followers rather than leaders. Insecure-ambivalent children have a tendency
to anxiously but unsuccessfully seek positive peer interaction whereas insecure-avoidant children appear aggressive
and hostile and may actively repudiate positive peer interaction. There is no established direct association between
early experience and a comprehensive measure of social functioning in early adulthood but early experience
significantly predicts early childhood representations of relationships, which in turn predicts later self and
relationship representations and social behaviour.However, studies have suggested that infants with a high-risk for
Autism Spectrum Disorders (ASD) may express attachment security differently from infants with a low-risk for
ASD.[15] Behavioural problems and social competence in insecure children increase or decline with deterioration or
improvement in quality of parenting and the degree of risk in the family environment. Avoidant children are
especially vulnerable to family risk. However an early secure attachment appears to have a lasting protective
function.[16]
Criticism
Michael Rutter describes the procedure in the following terms:[17]
"It is by no means free of limitations (see Lamb,
Thompson, Gardener, Charnov & Estes, 1984).[18] To
begin with, it is very dependent on brief separations and
reunions having the same meaning for all children. This
maybe a major constraint when applying the procedure
in cultures, such as that in Japan (see Miyake et al.,
1985), where infants are rarely separated from their
mothers in ordinary circumstances.[19] Also, because
older children have a cognitive capacity to maintain
relationships when the older person is not present,
separation may not provide the same stress for them.
Modified procedures based on the Strange Situation
Father and child
have been developed for older preschool children (see
Belsky et al., 1994; Greenberg et al., 1990) but it is
much more dubious whether the same approach can be used in middle childhood.[20] [21] Also, despite
its manifest strengths, the procedure is based on just 20 minutes of behaviour. It can be scarcely
expected to tap all the relevant qualities of a child's attachment relationships. Q-sort procedures based on
much longer naturalistic observations in the home, and interviews with the mothers have developed in
order to extend the data base (see Vaughn & Waters, 1990).[22] A further constraint is that the coding
procedure results in discrete categories rather than continuously distributed dimensions. Not only is this
likely to provide boundary problems, but also it is not at all obvious that discrete categories best
represent the concepts that are inherent in attachment security. It seems much more likely that infants
vary in their degree of security and there is need for a measurement systems that can quantify individual
variation".
186
Ecological validity and universality of Strange Situation attachment classification

distributions
attachment categorizations to be A (21%), B (65%), and C (14%).[23] This global distribution was generally
classifications noted above. One study was conducted in North Germany in which more avoidant (A) infants were
found than global norms would suggest, and the other in Sapporo, Japan, where more resistant (C) infants were
found.[24] [25] Of these two studies, the Japanese findings have sparked the most controversy as to the meaning of
In a recent study conducted in Sapporo, Behrens et al. (2007) found attachment distributions consistent with global
norms using the six-year Main & Cassidy scoring system for attachment classification.[26] [27] In addition to these
Van Ijzendoorn and Kroonenberg conducted a meta-analysis of various countries, including Japan, Israel, Germany,
China, the UK and the USA using the Strange Situation. The research showed that though there were cultural
differences, the three basic patterns, secure, avoidant and ambivalent, can be found in every culture in which studies
have been undertaken, even where communal sleeping arrangements are the norm. Selection of the secure pattern is
found in the majority of children across cultures studied. This follows logically from the fact that attachment theory
provides for infants to adapt to changes in the environment, selecting optimal behavioural strategies.[28] How
attachment is expressed shows cultural variations which need to be ascertained before studies can be undertaken.[28]

conjunction with discrete attachment classifications in many published reports (see Richters et al., 1998; Van
IJzendoorn et al., 1990).[29] [30] The original Richters et al. (1998) scale is strongly related to secure versus insecure
classifications, correctly predicting about 90% of cases.[30] Readers further interested in the categorical versus
continuous nature of attachment classifications (and the debate surrounding this issue) should consult a paper by
Fraley and Spieker and the rejoinders in the same issue by many prominent attachment researchers including J.
Cassidy, A. Sroufe, E. Waters & T. Beauchaine, and M. Cummings.[31]
References
[1] Tronick, Morelli, & Ivey, 1992, p.568. "Until recently, scientific accounts ... of the infant's early social experiences converged on the view
that the infant progresses from a primary relationship with one individual... to relationships with a growing number of people... This is an
epigenetic, hierarchical view of social development. We have labeled this dominant view the continuous care and contact model (CCC...). The
CCC model developed from the writings of Spitz..., Bowlby..., and Provence and Lipton... on institutionalized children and is represented in
the psychological views of Bowlby...[and others]. Common to the different conceptual frameworks is the belief that parenting practices and
the infant's capacity for social engagement are biologically based and conform to a prototypical form. Supporters of the CCC model generally
recognize that the infant and caregiver are able to adjust to a range of conditions, but they consider the adjustments observed to reflect
biological variation. However, more extreme views (e.g., maternal bonding) consider certain variants as nonadaptive and as compromising the
child's psychological development. Bowlby's concept of monotropism is an exemplar of the CCC perspective..." (Tronick, Morelli, & Ivey,
1992, p. 568).
[2] Kayastha, P. (2010). Security of attachment in children and adolescents. Bangalore:Elsevier B.V
187
[3]
[4]
[5]
[6]
[7]
Bowlby, J. (1969). Attachment and loss: Vol. I: Attachment. New York: Basic Books.
Bowlby, J. (1973). Attachment and loss: Vol. II: Separation: Anxiety and anger. New York: Basic Books.
Bowlby, J. (1980). Attachment and loss: Vol. III: Loss. New York: Basic Books.
Handbook of Attachment, edited by Shaver and Cassidy, 2009, Guilford Press, NY.
Ainsworth, M.D.S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation.
Hillsdale, NJ: Earlbaum.
[8] J. Cassidy & P. Shaver, (1999) Handbook of Attachment, NY:Guilford
[9] Main, M & Solomon, J., (1990). In Greenberg, M. T., Cicchetti, D., & Cummings, M. (Eds.),. Attachment in the preschool years: Theory,
research, and intervention (pp. 121-160). The University of Chicago Press: Chicago.
[10] Zeanah CH, Keyes A, Settles L (2003). "Attachment relationship experiences and childhood psychopathology". Ann. N. Y. Acad. Sci. 1008
(1): 2230. doi:10.1196/annals.1301.003. PMID14998869.
[11] Van IJzendoorn M. H., Schuengel C., Bakermans Kranenburg M. J. (1999). Disorganized attachment in early childhood: Meta-analysis of
precursors, concomitants, and sequelae. Development and Psychopathology, 11, 225-249.
[12] Carlson, V.; Cicchetti, D.; Barnett, D.; Braunwald, K. (1989). "Disorganized/disoriented attachment relationships in maltreated infants".
Developmental Psychology 25 (4): 525531. doi:10.1037/0012-1649.25.4.525.
[13] Lyons-Ruth K, Jacobvitz C (1999) "Attachment Disorganization: Unresolved Loss, Relational Violence, and Lapses in Behavioral and
Attentional Strategies". In Cassidy J and Shaver PR (Eds.) Handbook of Attachment: Theory, Research and Clinical Applications. pp.
89111. Guilford Press ISBN 1-57230-087-6.
[14] Lyons-Ruth K, Yellin C, Helnick S, Atwood G (2005). "Expanding the concept of unresolved mental states: Hostile/Helpless states of mind
on the Adult Attachment Interview are associated with disrupted mother-infant communication and infant disorganization". Dev Psychopathol
17 (1): 123. doi:10.1017/S0954579405050017. PMC1857275. PMID15971757.
[15] Haltigan, JD; Ekas NV; Seifer R; Messinger DS (July 2011). "Attachment security in infants at-risk for autism spectrum disorders." (http:/ /
web. ebscohost. com/ ehost/ detail?vid=3& hid=7& sid=4ee26e89-71a6-4d34-930d-cfd04877e6fa@sessionmgr11&
bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==#db=cmedm& AN=20859669). Attachment security in infants at-risk for autism spectrum disorders
41 (7): 962-967. . Retrieved 1 December 2011.
[16] Berlin LJ, Cassidy J, Appleyard K. "The Influence of Early Attachments on Other Relationshipsencyclopedia=Handbook of Attachment:
Theory, Research and Clinical Applications". In Cassidy J, Shaver PR. The Influence of Early Attachments on Other
Relationshipsencyclopedia=Handbook of Attachment: Theory, Research and Clinical Applications. New York and London: Guilford Press.
pp.33347. ISBN9781593858742.
[17] Rutter, M. (1995). "Clinical implications of attachment concepts: Retrospect and Prospect". Journal of Child Psychology and Psychiatry and
Allied Disciplines 36: 549571.
biological interpretations. Behavioural and Brain Sciences, 7, 127-147
[22] Vaughn, B. E.; Waters, E. et al. (1990). "Attachment behaviour at home and in the laboratory". Child Development 61 (6): 19651973.
PMID2083508.
[23] Van IJzendoorn, M.H.; Kroonenberg, P.M. (1988). "Cross-cultural patterns of attachment: A meta-analysis of the strange-situation". Child
Development 59: 147156.
[24] Grossmann, K.; Grossmann, K.E.; Huber, F.; Wartner, U. et al. (1981). "German children's behavior toward their mothers at 12 months and
their fathers at 18 months in Ainsworth's strange situation". International Journal of Behavioral Development 4: 157184.
doi:10.1177/016502548100400202.
[25] Takahashi, K. (1986). "Examining the Strange-Situation procedure with Japanese mothers and 12-month old infants". Developmental
Psychology 22 (2): 265270. doi:10.1037/0012-1649.22.2.265.
[26] Behrens, K. Y.; Main, M.; Hesse, E. (2007). "Mothers' Attachment Status as Determined by the Adult Attachment Interview Predicts Their
6-Year-Olds' Reunion Responses: A Study Conducted in Japan". Developmental Psychology 43 (6): 15531567.
doi:10.1037/0012-1649.43.6.1553. PMID18020832.
[27] Main, M.; Cassidy, J. (1988). "Categories of response to reunion with the parent at age 6: Predictable from infant attachment classifications
and stable over a 1-month period". Developmental Psychology 24 (3): 415426. doi:10.1037/0012-1649.24.3.415.
[28] van IJzendoorn MH, Sagi-Schwartz A (2008). "Cross-Cultural Patterns of Attachment; Universal and Contextual Dimensions". In Cassidy J,
Shaver PR. Handbook of Attachment: Theory, Research and Clinical Applications. New York and London: Guilford Press. pp.880905.
ISBN9781593858742.
[29] Richters, J. E.; Waters, E.; Vaughn, B. E. (1988). "Empirical classification of infant-mother relationships from interactive behavior and
crying during reunion". Child Development 59 (2): 512522. doi:10.2307/1130329. JSTOR1130329. PMID3359869.
188
[30] Van IJzendoorn, M. H.; Kroonenberg, P. M. (1990). "Cross-cultural consistency of coding the strange situation". Infant Behavior and
Development 13 (4): 469485. doi:10.1016/0163-6383(90)90017-3.
[31] Fraley, C. R.; Spieker, S. J. (2003). "Are Infant Attachment Patterns Continuously or Categorically Distributed? A Taxometric Analysis of
Strange Situation Behavior". Developmental Psychology 39 (3): 387404. doi:10.1037/0012-1649.39.3.387. PMID12760508.
32. The First Years Last Forever (2005) [DVD]. Washington, D.C. : Parents' Action for Children.
Recommended Reading
Cassidy, J., & Shaver, P., (Eds). (1999) Handbook of Attachment: Theory, Research, and Clinical Applications.
Guilford Press, NY.
Greenberg, MT, Cicchetti, D., & Cummings, EM., (Eds) (1990) Attachment in the Preschool Years: Theory,
Research and Intervention University of Chicago, Chicago.
Greenspan, S. (1993) Infancy and Early Childhood. Madison, CT: International Universities Press. ISBN
0-8236-2633-4.
Holmes, J. (1993) John Bowlby and Attachment Theory. Routledge. ISBN 0-415-07730-3.
Holmes, J. (2001) The Search for the Secure Base: Attachment Theory and Psychotherapy. London:
Brunner-Routledge. ISBN 1-58391-152-9.
Karen R (1998) Becoming Attached: First Relationships and How They Shape Our Capacity to Love. Oxford
University Press. ISBN 0-19-511501-5.
Zeanah, C., (1993) Handbook of Infant Mental Health. Guilford, NY.
Parkes, CM, Stevenson-Hinde, J., Marris, P., (Eds.) (1991) Attachment Across The Life Cycle Routledge. NY.
ISBN 0-415-05651-9
Siegler R., DeLoache, J. & Eisenberg, N. (2003) How Children develop. New York: Worth. ISBN 1-57259-249-4.
Bausch, Karl Heinz (2002) Treating Attachment Disorders NY: Guilford Press.
Mercer, J. Understanding Attachment, Praeger 2005.
189
Attachment measures
Attachment measures
Attachment measures refer to the various procedures used to assess attachment in children and adults.
Researchers have developed various ways of assessing patterns of attachment in children. A variety of methods
allow children to be classified into four attachment pattern groups: secure, anxious-ambivalent, anxious-avoidant,
and disorganized/disoriented, or assess disorders of attachment. These patterns are also referred to as Secure (Group
B); Anxious/Resistant (Group C); Avoidant (Group A) and Disorganized/Controlling (Group D). The
disorganized/controlling attachment classification is thought to represent a break-down in the attachment-caregiving
partnerhip such that the child does not have an organized behavioral or representational strategy to achieve
protection and care from the attachment figure. Each pattern group is further broken down into several
sub-categories. A child classified with the disorganized/controlling attachment will be given a "next best fit"
organized classification.
Attachment in adults is commonly measured using the Adult Attachment Interview, the Adult Attachment Projective
Picture System, and self-report questionnaires. Self-report questionnaires assess attachment style, a personality
dimension that describes attitudes about relationships with romantic partners. Attachment style is thought to be
similar to childhood attachment patterns, although there is to date no research that links how childhood attachment
patterns are related to attachment personality dimensions with romantic partners. The most common approach to
defining attachment style is a two-dimension approach in defining attachment style. One dimension deals with
anxiety about the relationship, and the other dimension dealing with avoidance in the relationship. Another approach
defines four adult attachment style categories: secure, preoccupied, dismissive-avoidant, and fearful-avoidant.
Measuring attachment in children

Some methods are based on observation of infants and toddlers either in natural or 'arranged' situations. Other
methods, suitable for older children, are based on asking children to complete "attachment story stems," draw a
picture of their family, or describe their relationships.
The Strange Situation

The Strange Situation procedure was formulated to observe attachment relationships between a caregiver and
children between the age of nine and 18 months. It was developed by Mary Ainsworth, a developmental
psychologist[1] Originally it was devised to enable children to be classified into the attachment styles known as
secure, anxious-avoidant and anxious-ambivalent. As research accumulated and atypical patterns of attachment
became more apparent it was further developed by Main and Solomon in 1986 and 1990 to include the new category
of disorganized/disoriented attachment.[2] [3]
In this procedure the child is observed playing for 20 minutes while caregivers and strangers enter and leave the
room, recreating the flow of the familiar and unfamiliar presence in most children's lives. The situation varies in
stressfulness and the child's responses are observed. The child experiences the following situations:
1.
2.
3.
4.
Mother (or other familiar caregiver) and baby enter room.

Mother sits quietly on a chair, responding if the infant seeks attention.
A stranger enters, talks to the mother then gradually approaches infant with a toy. The mother leaves the room.
The stranger leaves the infant playing unless he/she is inactive and then tries to interest the infant in toys. If the
infant becomes distressed this episode is ended.
5. Mother enters and waits to see how the infant greets her. The stranger leaves quietly and the mother waits until
the baby settles, and then she leaves again.
6. The infant is alone. This episode is curtailed if the infant appears to be distressed.
7. The stranger comes back and repeats episode 3.
190
Attachment measures
8. The mother returns and the stranger goes. Reunion behaviour is noted and then the situation is ended.
Two aspects of the child's behaviour are observed:
The amount of exploration (e.g. playing with new toys) the child engages in throughout, and
The child's reactions to the departure and return of its caregiver.
Developing methods for older toddlers and children

The Strange Situation is not designed for children older than about 18 months, and there is an ongoing effort to
develop assessment methods that are suitable for older toddlers and preschoolers, but has been modified for
preschool and elementary-school aged children, as described below. The methods in development are intended as
research measures, not as diagnostic techniques for individual children. As such, these techniques need to be "lean"
enough to carry out fairly quickly. They also need to include ways of guarding against "coder drift", the tendency of
evaluators to change their criteria as they assess more and more children over long periods of time. Effective training
of evaluators is essential, as some items to be assessed require interpretation reliability (e.g., child is "suddenly
aggressive toward mother for no reason").[4]
Preschool strange situation
A version of the Strange Situation procedure designed for an older age group of between 3 and 4 years by Cassidy,
Marvin and the MacArthur Working group.
Attachment Q-set
This method, devised by Waters and Deane in 1985, utilises Q-Sort methodology. It is based on a set period of
observation of children aged 1 5 in a number of environments. It consists of nearly 100 items intended to cover the
spectrum of attachment related behaviors including secure base and exploratory behaviors, affective response and
social cognition. It can rate a child along a continuum from secure to insecure but does not classify the type of
insecurity.[5] The current version is Attachment Q-set Version 3.0, 1987.
Main & Cassidy attachment classification system
This system, devised in 1988, analyses the reunion of child and parent after a 1 hour separation. It is aimed at 6 year
olds and classifies their attachment status.[6]
Preschool Assessment of Attachment (PAA)
The PAA was devised by P.Crittenden for the purpose of assessing patterns of attachment in 18-month to 5 year old
children. Like the SSP it involves an observation which is then coded. The classifications include all the SSP
categories plus patterns that develop during the second year of life. The three basic strategies for negotiating
interpersonal relationships are modified to fit preschoolers and the patterns are renamed secure/balanced, or Type B,
defended, or Type A and coercive or Type C. It is also intended to be able to distinguish the unendangered from the
endangered compulsive and obsessive subpatterns that may have implications for emotional and behavioral
development.[7]
Disturbances of Attachment Interview (DAI)
More recent research uses the Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah,
(1999). This is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12
items, namely having a discriminated, preferred adult, seeking comfort when distressed, responding to comfort when
offered, social and emotional reciprocity, emotional regulation, checking back after venturing away from the care
giver, reticence with unfamiliar adults, willingness to go off with relative strangers, self endangering behavior,
excessive clinging, vigilance/hypercompliance and role reversal. This method is designed to pick up not only
reactive attachment disorder but also Zeannah et al.'s (1993) suggested new alternative categories of disorders of
191
Attachment measures
attachment.[8]
Other approaches
With older toddlers, children, and teens, three different techniques to determine their state of mind with respect to
attachment are used. The first is the Story Stem in which children are asked to complete and describe stories having
been given the 'stem' or beginning. The second method asks children to respond to pictures. The third involves
asking children actual questions about their attachment relationships.
Narrative story stem techniques

This method uses dolls and narrative to enact a story. The dolls represent family members. The interviewer enacts
the beginning of the story and then hands the dolls over for the child to complete it with varying degrees of
prompting and encouragement. These techniques are designed to access the childs internal working models of their
attachment relationships. Methods include the MacArthur Story Stem Battery (MSSB) and the Attachment Story
Completion Test, developed in 1990 for children between the age of 3 to 8 years; the Story Stem Assessment Profile
(SSAP) developed in 1990 for children aged 4 8; the Attachment Doll Play Assessment developed in 1995 for
children age 4.5-11; the Manchester Child Attachment Story Task (MCAST) developed in 2000 for children aged
4.5 - 8.5.
Picture response techniques

Like the stem stories, these techniques are designed to access the childs internal working models of attachment
relationships. The child is shown attachment related pictures and asked to respond. Methods include the Separation
Anxiety Test (SAT) developed in 1972 for children aged between 11 and 17. Revised versions have been produced
for 4 - 7 year olds.
Direct interview techniques

Child Attachment Interview (CAI)
This is a semi-structured interview designed by Target et al. (2003) for children aged 7 to 11. It is based on the Adult
Attachment Interview, adapted for children by focussing on representations of relationships with parents and
attachment related events. Scores are based on both verbal and non-verbal communications.[9]
Attachment Interview for Childhood and Adolescence (AICA)
This again is a version of the Adult Attachment Interview (AAI) rendered age appropriate for adolescents. The
classifications of dismissing, secure, preoccupied and unresolved are the same as under the AAI described below.
Criticism
Existing measures have not necessarily been developed to a useful level. "Behavioral observation is a natural starting
point for assessing attachment disorders because behavioral descriptions... have been central to the development of
the concept... despite the fact that observations have figured prominently... no established observational protocol has
been established" [10]
Also, questionable measures of attachment in school-age children have been presented. For example, a protocol for
establishing attachment status was described by Sheperis and his colleagues [11] . Unfortunately, this protocol was
validated against another technique, the Randolph Attachment Disorder Questionnaire, that was itself poorly
validated and that is based on a nonconventional view of attachment.
192
Attachment measures
Reception and development of SSP

Psychiatrist Michael Rutter describe the limitations of the procedure in the following terms;[12]
"It is by no means free of limitations (see Lamb, Thompson,
Gardener, Charnov & Estes, 1984)[13] . To begin with, it is
very dependent on brief separations and reunions having the
same meaning for all children. This maybe a major constraint
when applying the procedure in cultures, such as that in Japan
(see Miyake et al.,, 1985)[14] , where infants are rarely
separated from their mothers in ordinary circumstances. Also,
because older children have a cognitive capacity to maintain
relationships when the older person is not present, separation
may not provide the same stress for them. Modified
procedures based on the Strange Situation have been
Mother and child
developed for older preschool children (see Belsky et al.,
1994; Greenberg et al., 1990)[15] [16] but it is much more
dubious whether the same approach can be used in middle childhood. Also, despite its manifest strengths, the
procedure is based on just 20 minutes of behaviour. It can be scarcely expected to tap all the relevant qualities
of a child's attachment relationships. Q-sort procedures based on much longer naturalistic observations in the
home, and interviews with the mothers have developed in order to extend the data base (see Vaughn & Waters,
1990)[17] . A further constraint is that the coding procedure results in discrete categories rather than
continuously distributed dimensions. Not only is this likely to provide boundary problems, but also it is not at
all obvious that discrete categories best represent the concepts that are inherent in attachment security. It seems
much more likely that infants vary in their degree of security and there is need for a measurement systems that
can quantify individual variation".
Ecological validity and universality of Strange Situation attachment classification

distributions
attachment categorizations to be A (21%), B (65%), and C (14%) [18] This global distribution was generally
classifications noted above. One study was conducted in North Germany [19] in which more avoidant (A) infants
were found than global norms would suggest, and the other in Sapporo, Japan [20] where more resistant (C) infants
were found. Of these two studies, the Japanese findings have sparked the most controversy as to the meaning of
In a recent study conducted in Sapporo, Behrens, et al., 2007.[21] found attachment distributions consistent with
global norms using the six-year Main & Cassidy scoring system for attachment classification.[22] In addition to these
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Attachment measures

conjunction with discrete attachment classifications in many published reports [see Richters et al., 1998;[23] Van
IJzendoorn et al., 1990).[24] ] The original Richters et al. (1998) scale is strongly related to secure versus insecure
classifications, correctly predicting about 90% of cases [24] . Readers further interested in the categorical versus
continuous nature of attachment classifications (and the debate surrounding this issue) should consult the paper by
Fraley and Spieker [25] and the rejoinders in the same issue by many prominent attachment researchers including J.
Cassidy, A. Sroufe, E. Waters & T. Beauchaine, and M. Cummings.
Measuring attachment in adults

The three main ways of measuring attachment in adults include the Adult Attachment Interview (AAI), the Adult
Attachment Projective Picture System (AAP), and self-report questionnaires. The AAI, AAP, and the self-report
questionnaires were created with somewhat different aims in mind. Shaver and Fraley note:
"If you are a novice in this research area, what is most important for you to know is that self-report
measures of romantic attachment and the AAI were initially developed completely independently and
for quite different purposes. One asks about a person's feelings and behaviors in the context of romantic
or other close relationships; the other is used to make inferences about the defenses associated with an
adult's current state of mind regarding childhood relationships with parents. In principle, these might
have been substantially associated, but in fact they seem to be only moderately related--at least as
currently assessed. One kind of measure receives its construct validity mostly from studies of romantic
relationships, the other from prediction of a person's child's behavior in Ainsworth's Strange Situation.
Correlations of the two kinds of measures with other variables are likely to differ, although a few studies
have found the AAI to be related to marital relationship quality and a few have found self-report
romantic attachment measures to be related to parenting." (Shaver & Fraley, 2004) [26]
The AAI and the self-report questionnaires offer distinct, but equally valid, perspectives on adult attachment. It's
therefore worthwhile to become familiar with both approaches.
Adult Attachment Interview (AAI)

Developed by Carol George, Nancy Kaplan, and Mary Main in 1984, this is a quasi-clinical semi-structured
interview that takes about one hour to administer. It involves about twenty questions and has extensive research
validation to support it. A good description can be found in Chapter 25 of Attachment Theory, Research and Clinical
Applications (2nd ed.), edited by J. Cassidy and P. R. Shaver, Guilford Press, NY, 2008. The chapter title is "The
Adult Attachment Interview: Historical and Current Perspectives," and is written by E. Hesse. The interview taps
into adult representation of attachment (i.e. internal working models) by assessing general and specific recollections
from their childhood. The interview is coded based on quality of discourse (especially coherence) and content.
Categories are designed to predict parental stances on Berkeley infant data.
Parental AAI Attachment status includes:
Autonomous: They value attachment relationships, describe them in a balanced way and as influential. Their
discourse is coherent, internally consistent, and non-defensive in nature.
Dismissing: They show memory lapses. Minimize negative aspects and deny personal impact on relationships.
Their positive descriptions are often contradicted or unsupported. The discourse is defensive.
Preoccupied: Experience continuing preoccupation with their own parents. Incoherent discourse. Have angry
or ambivalent representations of the past.
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Attachment measures
Unresolved/Disorganized:Show trauma resulting from unresolved loss or abuse.
Some of the strongest external validation of the measures involves its demonstrated ability to predict interviewees'
children's classifications in the Strange Situation. The measure also has been shown to have some overlap with
attachment constructs measured by the less time-intensive measures of the peer/romantic attachment tradition (Hazan
& Shaver, Bartholomew), as reported by Shaver, P. R., Belsky, J., & Brennan, K. A. (2000).[27] However, there are
important differences in what is measured by the AAIrather than being a measure of romantic attachment, it taps
primarily into a person's state of mind regarding their attachment in their family of origin (nuclear family).
Adult Attachment Projective Picture System (AAP)

Developed by Carol George and Malcolm West in 1999, this is a free response task that involved telling stories in
response to eight picture stimuli (1 warm-up & 7 attachment scenes). A good description can be found in George and
West's 1999 paper in the journal Attachment and Human Development. A book describing the measure is
forthcoming from Guilford Press in spring 2011.
The AAP identifies the same adult attachment groups as the AAI, as described above. In addition to providing adult
group classifications, the AAP is also used to code attachment defensive processing patterns, attachment synchrony,
and personal agency.
The strongest concurrent validation of the measure is the correspondence between AAP and AAI classification
agreement. The AAP is demonstrated to be increasingly useful in clinical and neurobiological settings. The AAP is
being used to assess attachment in adults and adolescents.
Self-report questionnaires
Hazan and Shaver created the first questionnaire to measure attachment in adults. [28] Their questionnaire was
designed to classify adults into the three attachment styles identified by Ainsworth. The questionnaire consisted of
three sets of statements, each set of statements describing an attachment style:
Secure - I find it relatively easy to get close to others and am comfortable depending on them and having them
depend on me. I don't often worry about being abandoned or about someone getting too close to me.
Avoidant - I am somewhat uncomfortable being close to others; I find it difficult to trust them completely,
difficult to allow myself to depend on them. I am nervous when anyone gets too close, and often, love partners
want me to be more intimate than I feel comfortable being.
Anxious/Ambivalent - I find that others are reluctant to get as close as I would like. I often worry that my
partner doesn't really love me or won't want to stay with me. I want to merge completely with another person,
and this desire sometimes scares people away.
People participating in their study were asked to choose which set of statements best described their feelings. The
chosen set of statements indicated their attachment style. Later versions of this questionnaire presented scales so
people could rate how well each set of statements described their feelings.
One important advance in the development of attachment questionnaires was the addition of a fourth style of
attachment. Bartholomew and Horowitz presented a model that identified four categories or styles of adult
attachment. [29] Their model was based on the idea attachment styles reflected people's thoughts about their partners
and thought about themselves. Specifically, attachment styles depended on whether or not people judge their partners
to be generally accessible and responsive to requests for support, and whether or not people judge themselves to be
the kind of individuals towards which others want to respond and lend help. They proposed four categories based on
positive or negative thoughts about partners and on positive or negative thoughts about self.
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Attachment measures
Bartholomew and Horowitz used this model to create the Relationship Questionnaire (RQ-CV). The RQ-CV
consisted of four sets of statements, each describing a category or style of attachment:
Secure - It is relatively easy for me to become emotionally close to others. I am comfortable depending on
others and having others depend on me. I don't worry about being alone or having others not accept me.
Dismissive - I am comfortable without close emotional relationships. It is very important to me to feel
independent and self-sufficient, and I prefer not to depend on others or have others depend on me.
Preoccupied - I want to be completely emotionally intimate with others, but I often find that others are
reluctant to get as close as I would like. I am uncomfortable being without close relationships, but I sometimes
worry that others don't value me as much as I value them.
Fearful - I am somewhat uncomfortable getting close to others. I want emotionally close relationships, but I
find it difficult to trust others completely, or to depend on them. I sometimes worry that I will be hurt if I allow
myself to become too close to others.
Tests demonstrated the four attachment styles were distinct in how they related to other kinds of psychological
variables. Adults indeed appeared to have four styles of attachment instead of three attachment styles.
David Schmitt, together with a large number of colleagues, validated the attachment questionnaire created by
Bartholomew and Horowitz in 62 cultures. [30] The distinction of thoughts about self and thoughts about partners
proved valid in nearly all cultures. However, the way these two kinds of thoughts interacted to form attachment
styles varied somewhat across cultures. The four attachment styles had somewhat different meanings across cultures.
A second important advance in attachment questionnaires was the use of independent items to assess attachment.
Instead of asking people to choose between three or four sets of statements, people rated how strongly they agreed
with dozens of individual statements. The ratings for the individual statements were combined to provide an
attachment score. Investigators have created several questionnaires using this strategy to measure adult attachment.
Two popular questionnaires of this type are the Experiences in Close Relationships (ECR) questionnaire and the
Experiences in Close Relationships - Revised (ECR-R) questionnaire. The ECR was created by Brennan, Clark, and
Shaver in 1998. [31] The ECR-R was created by Fraley, Waller, and Brennan in 2000. [32] Readers who wish to take
the ECR-R and learn their attachment style can find an online version of the questionnaire at http:/ / www.
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Attachment measures
web-research-design.net/cgi-bin/crq/crq.pl.
Analysis of the ECR and ECR-R reveal that the questionnaire items can be grouped into two dimensions of
attachment. One group of questionnaire items deal with how anxious a person is about their relationship. These items
serve as a scale for anxiety. The remaining items deal with how avoidant a person is in their relationship. These
items serve as a scale for avoidance. Many researchers now use scores from the anxiety and avoidance scales to
perform statistical analyses and test hypotheses.
Scores on the anxiety and avoidance scales can still be used to classify people into the four adult attachment styles.
[31] [33] [34]
The four styles of attachment defined in Bartholomew and Horowitz's model were based on thoughts
about self and thoughts about partners. The anxiety scale in the ECR and ECR-R reflect thoughts about self.
Attachment anxiety relates to beliefs about self-worth and whether or not one will be accepted or rejected by others.
The avoidance scale in the ECR and ECR-R relates to thoughts about partners. Attachment avoidance relates to
beliefs about taking risks in approaching or avoiding other people. Combinations of anxiety and avoidance can thus
be used to define the four attachment styles. The secure style of attachment is characterized by low anxiety and low
avoidance; the preoccupied style of attachment is characterized by high anxiety and low avoidance; the dismissive
avoidant style of attachment is characterized by low anxiety and high avoidance; and the fearful avoidant style of
attachment is characterized by high anxiety and high avoidance.
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Attachment measures
References
[1] Ainsworth. Mary D. (1978) Patterns of Attachment: A Psychological Study of the Strange Situation. Lawrence Erlbaum Associates. ISBN
0-89859-461-8.
[2] Main,M. and Solomon,J. (1986) 'Discovery of an insecure disorganized/dioriented attachment pattern:procedures, findings and implications
for the classification of behavior.' In t. Braxelton and M.Yogman (eds) Affective development in infancy. Norwood, NJ: Ablex
[3] Main,m. and Solomon,J. (1990) 'Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation' In
M.Greenberg, D. Cicchetti and E. Cummings (eds) Attachment in the preschool years: Theory, research and intervention. Chicago: University
of Chicago Press.
[4] Andreassen, C., & West, J. (2007). Measuring socioemotional functioning in a national birth cohort study. Infant Mental Health Journal,
28(6), 627-646.
[5] Waters Waters,E. and deane,K (1985) 'Defining and assessing individual differences in attachment relationships: Q-methodology and the
organization of behavior in infancy and early childhood.' In I.Bretherton and E. Waters (eds) Growing pains of attachment theory and
research: Monographs of the Society for Research in Child Development 50, Serial No. 209 (1-2), 41-65
[6] Main, M. & Cassidy, J. (1988) "Categories of response to reunion with the parent at age 6: predictable from infant attachment classifications
and stable over a 1-month period. Developmental Psychology 24, 415-426.
[7] Crittenden PM (1992). "Quality of attachment in the preschool years" (http:/ / www. patcrittenden. com/ Preschool-assesment. html).
Development and Psychopathology 4 (02): 20941. doi:10.1017/S0954579400000110. . Retrieved 2008-01-06.
[8] Smyke,A. and Zeanah,C. (1999)'Disturbances of Attachment Interview'. Available on the Journal of the American Academy of Child and
Adolescent Psychiatry website at www.jaacap.com
[9] Target,M., Fonagy,P. and Schmueli-Goetz,Y. (2003) 'Attachment representations in school-age children: the development of the Child
Attachment Interview (CAI).' Journal of Child Psychotherapy 29, 2, 171-186
[10] O'Connor, T., & Zeanah, C.H. (2003)."Attachment disorders: Assessment strategies and treatment approaches." Attachment & Human
Development, 5(3):223-244, p. 229
[11] Sheperis, C.J.,Doggett, R.A., Hoda, N.E., Blanchard, T., Renfro-Michael, E.L., Holdiness, S.H., & Schlagheck, R. (2003). "The
development of an assessment protocol for Reactive Attachment Disorder."Journal of Mental Health Counseling, 25(4):291-310
[12] "The Clinical Implications of Attachment Concepts". Journal of Child Psychology and Psychiatry 36 (4): 552553
biological interpretations. Behavioural and Brain Sciences, 7, 127-147
[17] Vaughn, B. E. & Waters, E. (1990). Attachment behaviour at home and in the laboratory. Child Development, 61, 1965-1973.
[18] Van IJzendoorn, M.H., & Kroonenberg, P.M. (1988). Cross-cultural patterns of attachment: A meta-analysis of the strange-situation. Child
[19] Grossmann, K.E., Grossmann, K., Huber, F., & Wartner, U. (1981). German children's behavior toward their mothers at 12 months and their
fathers at 18 months in Ainsworth's strange situation. International Journal of Behavioral Development, 4, 157-184.
[20] Takahashi, K. (1986). Examining the Strange-Situation procedure with Japanese mothers and 12-month old infants. Developmental
[21] Behrens, K. Y., Main, M., & Hesse, E. (2007). Mothers Attachment Status as Determined by the Adult Attachment Interview Predicts Their
6-Year-Olds Reunion Responses: A Study Conducted in Japan. Developmental Psychology, 43, 15531567.
[22] Main, M., & Cassidy, J. (1988). Categories of response to reunion with the parent at age 6: Predictable from infant attachment classifications
and stable over a 1-month period. Developmental Psychology, 24, 415-426.
[23] Richters, J. E., Waters, E., & Vaughn, B. E. (1988). Empirical classification of infant-mother relationships from interactive behavior and
crying during reunion. Child Development, 59, 512-522.
[24] Van IJzendoorn, M. H., & Kroonenberg, P. M. (1990). Cross-cultural consistency of coding the strange situation. Infant Behavior and
[25] Fraley, C. R., & Spieker, S. J. (2003). Are Infant Attachment Patterns Continuously or Categorically Distributed? A Taxometric Analysis of
Strange Situation Behavior. Developmental Psychology, 39, 387-404.
[26] Shaver, P.A. & Fraley, R.C. (2004). Self-report measures of adult attachment. Online article. Retrieved June 20, 2006, from http:/ / www.
psych. uiuc. edu/ ~rcfraley/ measures/ measures. html .
[27] Shaver, P. R., Belsky, J., & Brennan, K. A. (2000). The adult attachment interview and self-reports of romantic attachment: Associations
across domains and methods. Personal Relationships, 7, 25-43.
[28] Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachmenpt process. Journal of Personality and Social Psychology, 52,
511-524.
198
Attachment measures
[29] Bartholomew, K. & Horowitz, L.M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality
and Social Psychology, 61, 226-244.
[30] Schmitt, D.P., et al. (2004). Patterns and universals of adult romantic attachment across 62 cultural regions. Journal of Cross-Cultural
[31] Brennan, K.A., Clark, C.L., & Shaver, P.R. (1998). Self-report measurement of adult romantic attachment: An integrative overview. In J.A.
Simpson & W.S. Rholes (Eds.), Attachment theory and close relationships (pp. 46-76). New York: Guilford Press.
[32] Fraley, R.C., Waller, N.G., & Brennan, K.A. (2000). An item-response theory analysis of self-report measures of adult attachment. Journal
of Personality and Social Psychology, 78, 350-365.
[33] Bartholomew, K. & Shaver, P.R. (1998). Methods of assessing adult attachment. In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory
and close relationships, pp. 25-45. New York, NY: Guilford Press.
[34] Collins, N.L. & Freeney, B.C. (2004). An Attachment Theory Perspective on Closeness and Intimacy. In D.J. Mashek & A. Aron (Eds.),
Handbook of Closeness and Intimacy, pp. 163-188. Mahwah, NJ: Lawrence Erlbaum Associates.
Further reading
Cassidy, J., & Shaver, P., (Eds). (1999) Handbook of Attachment: Theory, Research, and Clinical Applications.
Guilford Press, NY.
Greenberg, MT, Cicchetti, D., & Cummings, EM., (Eds) (1990) Attachment in the Preschool Years: Theory,
Research and Intervention University of Chicago, Chicago.
Greenspan, S. (1993) Infancy and Early Childhood. Madison, CT: International Universities Press. ISBN
0-8236-2633-4.
Holmes, J. (1993) John Bowlby and Attachment Theory. Routledge. ISBN 0-415-07730-3.
Holmes, J. (2001) The Search for the Secure Base: Attachment Theory and Psychotherapy. London:
Brunner-Routledge. ISBN 1-58391-152-9.
Karen R (1998) Becoming Attached: First Relationships and How They Shape Our Capacity to Love. Oxford
University Press. ISBN 0-19-511501-5.
Parkes, CM, Stevenson-Hinde, J., Marris, P., (Eds.) (1991) Attachment Across The Life Cycle Routledge. NY.
ISBN 0-415-05651-9
Siegler R., DeLoache, J. & Eisenberg, N. (2003) How Children develop. New York: Worth. ISBN 1-57259-249-4.
External links
Relationship Advice: How Understanding Adult Attachment Can Help (http://www.helpguide.org/mental/
relationship_advice_adult_attachment.htm)
Attachment Questionnaire (http://www.web-research-design.net/cgi-bin/crq/crq.pl)
Articles on attachment measures including 11 self-report measures with scoring instructions (http://www.
richardatkins.co.uk/atws/page/55.html)
199
Attachment therapy
Attachment therapy
Attachment therapy is the most commonly used term for a controversial category of alternative child mental health
interventions intended to treat attachment disorders.[1] The term generally includes accompanying parenting
techniques. Other names or particular techniques include "the Evergreen model", "holding time", "rage-reduction",
"compression therapy", "rebirthing", "corrective attachment therapy" and Coercive Restraint Therapy.[1] It is found
primarily but not exclusively in the United States and much of it is centered in about a dozen clinics in Evergreen,
Colorado where Foster Cline, one of the founders, established his clinic in the 1970s. This article describes this
particular set of interventions although in clinical literature the term "attachment therapy" is sometimes used loosely
to mean any intervention based, or claiming to be based, on attachment theory, particularly outside the USA.
Attachment therapy is a treatment used primarily with fostered or adopted children who have behavioral difficulties,
sometimes severe, but including disobedience and perceived lack of gratitude or affection for their caregivers. The
children's problems are ascribed to an inability to attach to their new parents because of suppressed rage due to past
maltreatment and abandonment. The common form of attachment therapy is holding therapy, in which a child is
firmly held (or lain upon) by therapists or parents. Through this process of restraint and confrontation, therapists seek
to produce in the child a range of responses such as rage and despair with the goal of achieving catharsis. In theory,
when the child's resistance is overcome and the rage is released, the child is reduced to an infantile state in which he
or she can be "re-parented" by methods such as cradling, rocking, bottle feeding and enforced eye contact. The aim is
to promote attachment with the new caregivers. Control over the children is usually considered essential and the
therapy is often accompanied by parenting techniques which emphasize obedience. These accompanying parenting
techniques are based on the belief that a properly attached child should comply with parental demands "fast, snappy
and right the first time" and should be "fun to be around".[2] These techniques have been implicated in several child
deaths and other harmful effects.[3]
This form of therapy, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and
is not considered to be part of mainstream psychology or, despite its name, to be based on attachment theory, with
which it is considered incompatible.[4] [5] It is primarily based on Robert Zaslow's rage-reduction therapy from the
1960s and '70s and on psychoanalytic theories about suppressed rage, catharsis, regression, breaking down of
resistance and defence mechanisms. Zaslow, Tinbergen, Martha Welch and other early proponents used it as a
treatment for autism, based on the now discredited belief that autism was the result of failures in the attachment
relationship with the mother.
It has been described as a potentially abusive and pseudoscientific intervention that has resulted in tragic outcomes
for children, including at least six documented child fatalities.[6] Since the 1990s there have been a number of
prosecutions for deaths or serious maltreatment of children at the hands of "attachment therapists" or parents
following their instructions. Two of the most well-known cases are those of Candace Newmaker in 2000 and the
Gravelles in 2003. Following the associated publicity, some advocates of attachment therapy began to alter views
and practices to be less potentially dangerous to children. This change may have been hastened by the publication of
a Task Force Report on the subject in January 2006, commissioned by the American Professional Society on the
Abuse of Children (APSAC) which was largely critical of attachment therapy.[7] In April 2007, ATTACh, an
organization originally set up by attachment therapists, formally adopted a White Paper stating its unequivocal
opposition to the use of coercive practices in therapy and parenting, promoting instead newer techniques of
attunement, sensitivity and regulation.[8] Some leading attachement therapists have also specifically moved away
from coercive practices.
This form of treatment differs significantly from evidence-based attachment-based therapies, talking psychotherapies
such as attachment-based psychotherapy and relational psychoanalysis or the form of attachment parenting
advocated by the pediatrician William Sears. Further, the form of rebirthing sometimes used within attachment
therapy differs from Rebirthing-Breathwork.
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Attachment therapy
Treatment characteristics
The controversy, as outlined in the 2006 American Professional Society on the Abuse of Children (APSAC) Task
Force Report,[7] has broadly centered around "holding therapy"[9] and coercive, restraining, or aversive procedures.
These include deep tissue massage, aversive tickling, punishments related to food and water intake, enforced eye
contact, requiring children to submit totally to adult control over all their needs, barring normal social relationships
outside the primary caretaker, encouraging children to regress to infant status, reparenting, attachment parenting, or
techniques designed to provoke cathartic emotional discharge. Variants of these treatments have carried various
labels that change frequently. They may be known as "rebirthing therapy", "compression therapy", "corrective
attachment therapy", "the Evergreen model", "holding time", "rage-reduction therapy"[1] or "prolonged parent-child
embrace therapy".[10] Some authors critical of this therapeutic approach have used the term Coercive Restraint
Therapy.[11] It is this form of treatment for attachment difficulties or disorders which is popularly known as
"attachment therapy".[1] Advocates for Children in Therapy, a group that campaigns against attachment therapy, give
a list of therapies they state are attachment therapy by another name.[12] They also provide a list of additional
therapies used by attachment therapists which they consider to be unvalidated.[13]
Matthew Speltz of the University of Washington School of Medicine describes a typical treatment taken from The
Center's material (apparently a replication of the program at the Attachment Center, Evergreen) as follows:
"Like Welsh (sic)(1984, 1989), The Center induces rage by physically restraining the child and forcing
eye contact with the therapist (the child must lie across the laps of two therapists, looking up at one of
them). In a workshop handout prepared by two therapists at The Center, the following sequence of
events is described: (1) therapist 'forces control' by holding (which produces child 'rage'); (2) rage leads
to child 'capitulation' to the therapist, as indicated by the child breaking down emotionally ('sobbing');
(3) the therapist takes advantage of the child's capitulation by showing nurturance and warmth; (4) this
new trust allows the child to accept 'control' by the therapist and eventually the parent. According to The
Center's treatment protocol, if the child 'shuts down' (i.e., refuses to comply), he or she may be
threatened with detainment for the day at the clinic or forced placement in a temporary foster home; this
is explained to the child as a consequence of not choosing to be a 'family boy or girl.' If the child is
actually placed in foster care, the child is then required to 'earn the way back to therapy' and a chance to
resume living with the adoptive family."[14]
According to the APSAC Task Force,
"A central feature of many of these therapies is the use of psychological, physical, or aggressive means
to provoke the child to catharsis, ventilation of rage, or other sorts of acute emotional discharge. To do
this, a variety of coercive techniques are used, including scheduled holding, binding, rib cage
stimulation (e.g., tickling, pinching, knuckling), and/or licking. Children may be held down, may have
several adults lie on top of them, or their faces may be held so they can be forced to engage in prolonged
eye contact. Sessions may last from 3 to 5 hours, with some sessions reportedly lasting longer... Similar
but less physically coercive approaches may involve holding the child and psychologically encouraging
the child to vent anger toward her or his biological parent."[2]
The APSAC Task Force describes how the conceptual focus of these treatments is the child's individual internal
pathology and past caregivers rather than current parent-child relationships or current environment. If the child is
well-behaved outside the home this is seen as successful manipulation of outsiders, rather than as evidence of a
problem in the current home or current parent-child relationship. The APSAC Task Force noted that this perspective
has its attractions because it relieves the caregivers of responsibility to change aspects of their own behavior and
aspirations. Proponents believe that traditional therapies fail to help children with attachment problems because it is
impossible to establish a trusting relationship with them. They believe this is because children with attachment
problems actively avoid forming genuine relationships. Proponents emphasize the child's resistance to attachment
and the need to break it down. In rebirthing and similar approaches, protests of distress from the child are considered
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Attachment therapy
to be resistance that must be overcome by more coercion.[15]
Coercive techniques, such as scheduled or enforced holding, may also serve the intended purpose of demonstrating
dominance over the child. Establishing total adult control, demonstrating to the child that he or she has no control,
and demonstrating that all of the child's needs are met through the adult, is a central tenet of many controversial
attachment therapies. Similarly, many controversial treatments hold that children described as attachmentdisordered
must be pushed to revisit and relive early trauma. Children may be encouraged to regress to an earlier age where
trauma was experienced or be reparented through holding sessions.[15] Other features of attachment therapy are the
"two week intensive" course of therapy, and the use of "therapeutic foster parents" with whom the child stays whilst
undergoing therapy. According to O'Connor and Zeanah, the "holding" approach would be viewed as intrusive and
therefore non-sensitive and countertherapeutic, in contrast with accepted theories of attachment.[4]
According to Advocates for Children in Therapy,
"Attachment Therapy almost always involves extremely confrontational, often hostile confrontation of a
child by a therapist or parent (sometimes both). Restraint of the child by more powerful adult(s) is
considered an essential part of the confrontation." The purported correction is described as "...to force
the children into loving (attaching to) their parents; ... there is a hands-on treatment involving physical
restraint and discomfort. Attachment Therapy is the imposition of boundary violations most often
coercive restraint and verbal abuse on a child, usually for hours at a time; ... Typically, the child is put
in a lap hold with the arms pinned down, or alternatively an adult lies on top of a child lying prone on
the floor."[16]
Psychiatrist Bruce Perry cites the use of holding therapy techniques by caseworkers and foster parents investigating a
Satanic Ritual Abuse case in the late 1980s, early 1990s, as instrumental in obtaining lengthy and detailed alleged
"disclosures" from children. In his opinion, using force or coercion on traumatised children simply re-traumatizes
them and far from producing love and affection, produces obedience based on fear, as in the trauma bond known as
Stockholm syndrome.[17]
Parenting techniques
Therapists often instruct parents to follow programs of treatment at home, for example obedience-training techniques
such as "strong sitting" (frequent periods of required silence and immobility) and withholding or limiting food.[2] [18]
Earlier authors sometimes referred to this as "German Shepherd training".[19] In some programmes children
undergoing the two-week intensive stay with "therapeutic foster parents" for the duration or beyond and the adoptive
parents are trained in their techniques.[20]
According to the APSAC Task Force, because it is believed children with attachment problems resist attachment,
fight against it and seek to control others to avoid attaching, the child's character flaws must be broken before
attachment can occur. Attachment parenting may include keeping the child at home with no social contacts, home
schooling, hard labor or meaningless repetitive chores throughout the day, motionless sitting for prolonged periods
of time, and control of all food and water intake and bathroom needs. Children described as attachment-disordered
are expected by attachment therapists[21] to comply with parental commands "fast and snappy and right the first
time", and to always be "fun to be around" for their parents.[2] Deviation from this standard, such as not finishing
chores or arguing, is interpreted as a sign of attachment disorder that must be forcibly eradicated. From this
perspective, parenting a child with an attachment disorder is a battle, and winning the battle by defeating the child is
paramount.[2]
Proper appreciation of total adult control is also considered vital, and information, such as how long a child will be
with therapeutic foster parents or what will happen to him or her next, is deliberately withheld.[22] Attachment
parenting expert Nancy Thomas states that attachment-disordered children act worse when given information about
what is going to occur because they will use the information to manipulate their environment and everyone in it.[18]
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In addition to restrictive behavior, parents are advised to provide daily sessions in which older children are treated as
if they were babies to create attachment.[18] The child is held in the caregiver's lap, rocked, hugged and kissed, and
fed with a bottle and given sweets. These sessions are carried out at the caregiver's wish and not upon the child's
request. Attachment therapists believe that reenactments of aspects of infant care have the power to rebuild damaged
aspects of early development such as emotional attachment.[23]
Contrasting attachment theory based methods

In contrast, traditional attachment theory holds that the provision of a safe and predictable environment and caregiver
qualities such as sensitivity, responsiveness to children's physical and emotional needs and consistency, support the
development of healthy attachment. Therapy based on this viewpoint emphasizes providing a stable environment and
taking a calm, sensitive, non-intrusive, non-threatening, patient, predictable, and nurturing approach toward children.
Further, as attachment patterns develop within relationships, methods to correct problems with attachment focus on
improving the stability and positive qualities of the caregiver-child interactions and relationship.[24] [25] [26] All
mainstream interventions with an existing or developing evidential foundation focus on enhancing caregiver
sensitivity, creating positive interactions with caregivers, or change of caregiver if that is not possible with existing
caregivers.[27] [28] Some interventions focus specifically on increasing caregiver sensitivity in foster parents.[27] [28]
Theoretical principles
Like a number of other alternative mental health treatments for children, attachment therapy is based on some
assumptions that differ strongly from the theoretical foundations of other attachment based therapies.[15] In contrast
to traditional attachment theory, the theory of attachment described by attachment therapy proponents is that young
children who experience adversity (including maltreatment, loss, separations, adoption, frequent changes in child
care, colic or even frequent ear infections) become enraged at a very deep and primitive level.[15] This results in a
lack of ability to attach or to be genuinely affectionate to others. Suppressed or unconscious rage is theorized to
prevent the child from forming bonds with caregivers and leads to behavior problems when the rage erupts into
unchecked aggression. Such children are said to fail to develop a conscience, to not trust others, to seek control
rather than closeness, to resist the authority of caregivers, and to engage in endless power struggles. They are seen as
highly manipulative and as trying to avoid true attachments while simultaneously striving to control those around
them through manipulation and superficial sociability. Such children are said to be at risk of becoming psychopaths
who will go on to engage in very serious delinquent, criminal, and antisocial behaviors if left untreated.[15] The tone
in which the attributes of these children are described has been characterized as "demonizing".[29]
Advocates of this treatment also believe that emotional attachment of a child to a caregiver begins during the
prenatal period, during which the unborn child is aware of the mother's thoughts and emotions. If the mother is
distressed by the pregnancy, especially if she considers abortion, the child responds with distress and anger that
continue through postnatal life. If the child is separated from the mother after birth, no matter how early this occurs,
the child again feels distress and rage that will block attachment to a foster or adoptive caregiver.[30]
If the child has had a peaceful gestation, but after birth suffers pain or ungratified needs during the first year,
attachment will again be blocked. If the child reaches the toddler period safely, but is not treated with strict authority
during the second year, according to the so-called "attachment cycle", attachment problems will result. Failure of
attachment results in a lengthy list of mood and behavior problems, but these may not be revealed until the child is
much older. According to attachment therapist Elizabeth Randolph, attachment problems can be diagnosed even in
an asymptomatic child through observation of the child's inability to crawl backward on command.[31] [32]
Critics say holding therapies have been promoted as "attachment" therapies, even though they are more antithetical
to than consistent with attachment theory,[33] and not based on attachment theory or research.[6] Indeed they are
considered incompatible.[4] There are many ways in which holding therapy/attachment therapy contradicts Bowlby's
attachment theory, e.g. attachment theory's fundamental and evidence-based statement that security is promoted by
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sensitivity.[34] According to Mary Dozier "holding therapy does not emanate in any logical way from attachment
theory or from attachment research".[35]
Diagnosis and attachment disorder

Attachment therapists claim to diagnose attachment disorder,[36] and reactive attachment disorder.[37] However,
within attachment therapy, the diagnoses of attachment disorder and reactive attachment disorder are used in a
manner not recognised in mainstream practice. Prior and Glaser describe two discourses on attachment disorder.[38]
One is science-based, found in academic journals and books with careful reference to theory, international
classifications and evidence. They list Bowlby, Ainsworth, Tizard, Hodges, Chisholm, O'Connor and Zeanah and
colleagues as respected attachment theorists and researchers in the field. The other discourse is found in clinical
practice, non-academic literature and on the Internet where claims are made which have no basis in attachment
theory and for which there is no empirical evidence. In particular unfounded claims are made as to efficacy of
treatments.[38] The Internet is considered essential to the popularization of holding therapy as an "attachment"
therapy.[39]
The APSAC Task Force describes the relationship between the proponents of attachment therapy and mainstream
therapies as polarized. "This polarization is compounded by the fact that attachment therapy has largely developed
outside the mainstream scientific and professional community and flourishes within its own networks of attachment
therapists, treatment centers, caseworkers, and parent support groups. Indeed, proponents and critics of the
controversial attachment therapies appear to move in different worlds."[15]
Diagnosis lists and questionnaires

Both the APSAC Task Force and Prior and Glaser describe the proliferation of alternative "lists" and diagnoses,
particularly on the Internet, by proponents of attachment therapy, that are not in accord with either DSM or ICD
classifications and which are partly based on the unsubstantiated views of Zaslow and Menta[40] and Cline.[7] [19] [29]
According to the Task Force, "These types of lists are so nonspecific that high rates of false-positive diagnoses are
virtually certain. Posting these types of lists on internet sites that also serve as marketing tools may lead many
parents or others to conclude inaccurately that their children have attachment disorders."[41]
Prior and Glaser describe the lists as "wildly inclusive" and state that many of the behaviors in the lists are likely to
be the consequences of neglect and abuse rather than located within the attachment paradigm. Descriptions of
children are frequently highly pejorative and "demonizing". Examples given from lists of attachment disorder
symptoms found on the internet include lying, avoiding eye contact except when lying, persistent nonsense questions
or incessant chatter, fascination with fire, blood, gore and evil, food related issues (such as gorging or hoarding),
cruelty to animals and lack of conscience. They also give an example from the Evergreen Consultants in Human
Behavior which offers a 45-symptom checklist including bossiness, stealing, enuresis and language disorders.[29]
A commonly used diagnostic checklist in attachment therapy is the Randolph Attachment Disorder Questionnaire or
"RADQ", which originated at the Institute for Attachment in Evergreen.[42] It is presented not as an assessment of
reactive attachment disorder but rather attachment disorder. The checklist includes 93 discrete behaviors, many of
which either overlap with other disorders, like Conduct Disorder and Oppositional Defiant Disorder or are not
related to attachment difficulties.[43] It is largely based on the earlier Attachment Disorder Symptom Checklist which
itself shows considerable overlap with even earlier checklists for indicators of sexual abuse. The Attachment
Disorder Symptom Checklist includes statements about the parent's feelings toward the child as well as statements
about the child's behavior. For example, parental feelings are evaluated through responses to such statements as
"Parent feels used" and "is wary of the child's motives if affection is expressed", and "Parents feel more angry and
frustrated with this child than with other children". The child's behavior is referred to in such statements as "Child
has a grandiose sense of self-importance" and "Child 'forgets' parental instructions or directives". The compiler of
the RADQ claims validity by reference to the Attachment Disorder Symptom Checklist. It also purports to diagnose
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Attachment therapy
attachment disorder for which there is no classification.[44] A critic has stated that a major problem of the RADQ is
that it has not been validated against any established objective measure of emotional disturbance.[45]
Patient recruitment
In addition to concerns about the use of non-specific diagnostic checklists on the Internet being used as a marketing
tool, the Task Force also noted the extreme claims made by proponents as to both the prevalence and effect of
attachment disorders. Some proponents suggest most or a high proportion of adopted children are likely to suffer
attachment disorder. Statistics on the prevalence of maltreatment are wrongly used to estimate the prevalence of
RAD.[2] Problematical or less desirable styles such as insecure or disorganized attachment are conflated with
attachment disorder. Children are labeled as "RADs", "RAD-kids" or "RADishes".[2] They are seen as manipulative,
dishonest, without conscience and dangerous.[2] Some attachment therapy sites predict that attachment-disordered
children will grow up to become violent predators or psychopaths unless they receive the treatment proposed.[2] A
sense of urgency is created which serves to justify the application of aggressive and unconventional techniques.[2]
One site was noted to contain the argument that Saddam Hussein, Adolf Hitler, and Jeffrey Dahmer, were examples
of children who were attachment-disordered who "did not get help in time".[2] Foster Cline in his seminal work on
attachment therapy Hope for high risk and rage filled children uses the example of Ted Bundy.[19]
In answering the question posed as to how a treatment widely regarded by attachment clinicians and researchers as
destructive and unethical came to be linked with attachment theory and to be seen as a viable and useful treatment,
O'Connor and Nilson cite the use of the Internet to publicize attachment therapy and the lack of knowledgeable
mainstream professionals or appropriate mainstream treatments or interventions. They set out recommendations for
the better dissemination of both understanding of attachment theory and knowledge of the more recent
evidence-based treatment options available.[46]
Rachel Stryker in her anthropological study "The Road to Evergreen" argues that adoptive families of
institutionalized children who have difficulties transitioning to a nuclear family are attracted to the Evergreen model
despite the controversy, because it legitimises and reanimates the same ideas about family and domesticity as does
the adoption process itself, offering renewed hope of "normal" family life. Institutionalized or abused children often
do not conform to adopters conceptualizations of family behaviours and roles. The Evergreen model pathologizes the
childs behaviour by a medical diagnosis, thus legitimising the family. As well as the promise of working where
traditional therapies fail, attachment therapy also offers the idea of attachment as a negotiable social contract that can
be enforced in order to convert the unsatisfactory adoptee into the "emotional asset" the family requires. By the use
of confrontation the model offers the means to condition children to comply with parental expectations. Where the
therapy fails to achieve this the fault is attributed to the child's conscious choice to not be a family member, or the
child's inability to perform as family material.[20]
Contrasting mainstream position

Within mainstream practice, disorders of attachment are classified in DSM-IV-TR and ICD-10 as reactive
attachment disorder (generally known as RAD), and Disinhibited attachment disorder. Both classification systems
warn against automatic diagnosis based on abuse or neglect. Many symptoms are present in a variety of other more
common and more easily treatable disorders. There is as yet no other accepted definition of attachment disorders.[47]
According to the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter published in
2005, the question of whether attachment disorders can be reliably diagnosed in older children and adults has not
been resolved. Attachment behaviors used for the diagnosis of RAD change markedly with development and
defining analogous behaviors in older children is difficult. There are no substantially validated measures of
attachment in middle childhood or early adolescence.[28]
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Attachment therapy
Prevalence
Attachment therapy prospered during the 1980s and '90s as a consequence of both the influx of older adopted
orphans from Eastern European and third world countries and the inclusion of reactive attachment disorder in the
1980 Diagnostic and Statistical Manual of Mental Disorders which attachment therapists adopted as an alternative
name for their existing unvalidated diagnosis of attachment disorder.[48]
According to the APSAC Task Force, these therapies are sufficiently prevalent to have prompted position statements
or specific prohibitions against using coercion or restraint as a treatment by mainstream professional societies such
as: American Psychological Association (Division on Child Maltreatment), National Association of Social Workers
[49] (and its Utah Chapter), American Professional Society on the Abuse of Children,[7] American Academy of
Child and Adolescent Psychiatry,[28] and American Psychiatric Association. The Association for the Treatment and
Training in the Attachment of Children, (ATTACh), an organization for professionals and families associated with
attachment therapy, has also issued statements against coercive practices.[50] [51] Two American states, Colorado and
North Carolina, have outlawed rebirthing.[52] There have been professional licensure sanctions against some leading
proponents and successful criminal prosecutions and imprisonment of therapists and parents using attachment
therapy techniques. Despite this, the treatments appear to be continuing among networks of attachment therapists,
attachment therapy centers, caseworkers, and adoptive or foster parents.[15] The advocacy group ACT states,
"Attachment Therapy is a growing, underground movement for the 'treatment' of children who pose disciplinary
problems to their parents or caregivers."[13]
Rachel Stryker in her anthropological study "The Road to Evergreen" states that attachment therapies "of all stripes"
are increasingly popular in the USA and that the number of therapists associated with the Evergreen model
registering with ATTACh grows each year. She cites the large number of formerly institutionalized domestic and
foreign adoptees in the USA and the apparently higher risk of disruption of foreign adoptions, of which there were
216,000 between 1998 and 2008.[20]
The practice of holding therapy is not confined to the US. Prior and Glaser cite at least one clinic in the UK.[53]
Attachment therapists from the USA have conducted conferences in the UK.[20] The British Association for
Adoption and Fostering, (BAAF), has issued an extensive position statement on the subject which covers not only
physical coercion but also the underlying theoretical principles.[54] However, therapists calling themselves
"attachment therapists" practicing in the UK tend to be practicing conventional forms of psychotherapy based on
attachment theory.[55]
Developments
The APSAC Task Force stated that proponents of attachment therapy correctly point out that most critics have never
actually observed any of the treatments they criticize or visited any of the centers where the controversial therapies
are practiced. Proponents argue that their therapies present no physical risk if undertaken properly and that critics'
concerns are based on unrepresentative occurrences and misapplications of techniques, or misunderstanding by
parents. Holding is described as gentle or nurturing and it is maintained that intense, cathartic approaches are
necessary to help children with attachment disorders. Their evidence for this is primarily clinical experience and
testimonials.[15]
According to the APSAC Task Force, there are controversies within the attachment therapy community about
coercive practices. There has been a move away from coercive and confrontational models towards attunement and
emotional regulation amongst some leaders in the field, notably Hughes, Kelly and Popper. A number of therapies
are quite different from those that have led to the abuse and deaths of children in much publicized court cases. The
Task Force, however, points out that all the therapies, including those using frankly coercive practices, present
themselves as humane, respectful and nurturing, therefore caution is advised.[56] Some practitioners condemn the
most dangerous techniques but continue to practice other coercive techniques.[15] Others have taken a public stand
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Attachment therapy
against coercion. The Task Force was of the view that all could benefit from more transparency and specificity as to
how the therapy is behaviorally delivered.[56]
In 2001, 2003 and 2006, ATTACh, an organization set up by Foster Cline and associates, issued a series of
statements in which they progressively changed their stance on coercive practices. In 2001, after the death of
Candace Newmaker they stated "The child will never be restrained or have pressure put on them in such a manner
that would interfere with their basic life functions such as breathing, circulation, temperature, etc."[57] A White
Paper, formally accepted in April 2007, "unequivocally state(s) our opposition to the use of coercive practices in
therapy and parenting." They acknowledge ATTACh's historical links with catharsis, provocation of rage, and
intense confrontation, among other overtly coercive techniques (and indeed continue to offer for sale books by
controversial proponents) but state that the organization has evolved significantly away from earlier positions. They
state that their recent evolution is due to a number of factors including tragic events resulting from such techniques,
an influx of members practicing other techniques such as attunement and a "fundamental shift ... away from viewing
these children as driven by a conscious need for control toward an understanding that their often controlling and
aggressive behaviors are automatic, learned defensive responses to profoundly overwhelming experiences of fear and
terror."[8] [51] While being of the view that authoritative practices are necessary, and that nurturing touch and
treatment aimed at the perceived developmental rather than chronological age are an integral part of the therapy, the
White Paper promotes the techniques of attunement, sensitivity and regulation and deprecates coercive practices
such as enforced holding or enforced eye contact.[8]
A modest social work study and "invitation to a debate", based on interviews with the deliverers and recipients of a
therapeutic intervention incorporating non-coercive holding at one centre in the UK, reports generally positive
effects of the overall therapeutic process and calls for further consideration of the use of this type of intervention.
The intervention was not described as "holding therapy" but as using a degree of holding in the course of therapy.
The intervention also used a degree of intrusiveness, based on the idea that the recipients need this as they have no
basis on which to build a reciprocal relationship. Although recipients were generally positive about the therapy
received, the holding aspect was the least liked. The authors call for research and a debate on issues of what
constitutes "coercion" and the distinctions between the different variants of "holding" in therapy.[55]
History
Matthew Speltz of the University of Washington School of Medicine states that the roots of attachment therapy are
traceable to psychologist Robert Zaslow and his "Z-process" in the 1970s.[14] [40] Zaslow attempted to force
attachment in those suffering from autism by creating rage while holding them against their will. He believed this
would lead to a breakdown in their defense mechanisms, making them more receptive to others.[14] Zaslow thought
attachment arose when an infant experienced feelings of pain, fear and rage, and then made eye contact with the
carer who relieved those feelings. If an infant did not experience this cycle of events by having his fear and rage
relieved, the infant would not form an attachment and would not make eye contact with other people.[58] Zaslow
believed that creating pain and rage and combining them with eye contact would cause attachment to occur, long
after the normal age for such developments.[58] Holding therapies derive from these "rage-reduction" techniques
applied by Zaslow.[59] The holding is not used for safety purposes but is initiated for the purpose of provoking strong
negative emotions such as fear and anger. The child's release typically depends upon his or her compliance with the
therapist's clinical agenda or goals.[14] In 1971, Zaslow surrendered his California psychology license following an
injury to a patient during rage-reduction therapy.[60] Zaslow's ideas on the use of the Z-process and holding for
autism have been dispelled by research on the genetic/biologic causes of autism.[14]
Zaslow and his "Z-process", a physically rough version of holding therapy, influenced Foster Cline (known as the
"father of attachment therapy") and associates at his clinic in Evergreen[61] A key tenet of Zaslow's approach was the
notion of "breaking through" a child's defensesbased on the model of ego defenses borrowed from psychoanalytic
theory, which critics state has been misapplied. The "breaking through" metaphor was then applied to children whose
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attachments were thought to be impaired.[59] The clinic, originally called the Youth Behavior Program, was
subsequently renamed the Attachment Center at Evergreen.[62]
In 1983, ethologist Nikolas Tinbergen published a book recommending the use of holding therapy by parents as a
treatment or "cure" for autistic children. Tinbergen based his ideas on his methods of observational study of birds.
Parents were advised to hold their autistic children despite resistance and to endeavor to maintain eye contact and
share emotions.[63] Tinbergen believed that autism related to a failure in the bond between mother and child caused
by "traumatic influences" and that enforced holding and eye contact could establish such a relationship and rescue
the child from autism.[63] Tinbergen's interpretations of autism were without scientific rigor and were contrary to the
then growing acceptance that autism had a genetic cause. Despite the lack of a sound theoretical or scientific base,
holding therapy as a treatment for autism is still practiced in some parts of the world, notably Europe.[64]
Speltz cites child psychiatrist Martha Welch and her 1988 book, Holding Time,[9] as the next significant
development. Like Zaslow and Tinbergen, Welch recommended holding therapy as a treatment for autism.[9] Like
Tinbergen, Welch believed autism was caused by the failure of the attachment relationship between mother and
child.[65] Mothers were instructed to hold their defiant child, provoking anger and rage, until such time as the child
ceased to resist, at which point a bonding process was believed to begin.[9]
Foster Cline and associates at the Attachment Center at Evergreen, Colorado began to promote the use of the same or
similar holding techniques with adopted, maltreated children who were said to have an "attachment disorder". This
was replicated elsewhere such as at "The Center" in the Pacific Northwest.[14] A number of other clinics arose in
Evergreen, Colorado, set up by those involved in or trained at the Attachment Center at Evergreen (renamed the
Institute for Attachment and Development in about 2002).[62] These included one set up by Connell Watkins,
formerly an associate of Foster Cline at the Attachment Center and its clinical director. Watkins was one of the
therapists convicted in the Candace Newmaker case in 2001 in which a child was asphyxiated during a rebirthing
process in the course of a two-week attachment therapy "intensive".[66] Foster Cline gave up his license and moved
to another state following an investigation of a separate attachment therapy related incident.[62]
In addition to the notion of "breaking through" defence mechanisms, other metaphors were adopted by practitioners
relating to the supposed effects of early deprivation, abuse or neglect on the child's ability to form relationships.
These included the idea of the child's development being "frozen" and treatment being required to "unfreeze"
development.[59] Practitioners of holding therapy also added some components of Bowlby's attachment theory and
the therapy came to be known as attachment therapy. Language from attachment theory is used but descriptions of
the practices contain ideas and techniques based on misapplied metaphors deriving from Zaslow and psychoanalysis,
not attachment theory.[67] According to Prior and Glaser "there is no empirical evidence to support Zaslow's theory.
The concept of suppressed rage has, nevertheless, continued to be a central focus explaining the children's
behavior."[53]
Cline's privately-published work Hope for high risk and rage filled children also cites family therapist and
hypnotherapist Milton Erickson as a source, and reprints parts of a case of Erickson's published in 1961.[19] [68] The
report describes the case of a divorced mother with a non-compliant son. Erickson advised the mother to sit on the
child for hours at a time and to feed him only on cold oatmeal while she and a daughter ate appetizing food. The
child did increase in compliance, and Erickson noted, with apparent approval, that he trembled when his mother
looked at him. Cline commented, with respect to this and other cases, that in his opinion all bonds were trauma
bonds. According to Cline, it illustrates the three essential components of 1) taking control, 2) the child's expression
of rage; and, 3) relaxation and the development of bonding.[19]
In addition, proponents believed that holding induced age regression, enabling a child to make up for physical
affection missed earlier in life.[59] Regression is key to the holding therapy approach.[34] In attachment therapy,
breaking down the child's resistance by confrontational techniques is thought to reduce the child to an infantile state,
thus making the child receptive to forming attachment by the application of early parenting behaviors such as bottle
feeding, cradling, rocking and eye contact.[69] Some, but by no means all, attachment therapists have used rebirthing
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Attachment therapy
techniques to aid regression. The roots of the form of rebirthing used within attachment therapy lie in primal therapy
(sometimes known as primal scream therapy), another therapy based on beliefs in very early trauma and the
transformational nature of age regression.[48] Bowlby explicitly rejected the notion of regression stating "present
knowledge of infant and child development requires that a theory of developmental pathways should replace theories
that invoke specific phases of development in which it is held a person may become fixated and/or to which he may
regress."[53] [70]
According to O'Connor and Nilsen, although other aspects of treatment are applied, the holding component has
attracted most attention because proponents believe it is an essential ingredient. They also considered the lack of
available and suitable interventions from mainstream professionals as essential to the popularization of holding
therapy as an attachment therapy.[33]
In 2003, an issue of Attachment & Human Development was devoted to the subject of attachment therapy with
articles by well-known experts in the field of attachment.[71] Attachment researchers and authors condemned it as
empirically unfounded, theoretically flawed and clinically unethical.[4] It has also been described as potentially
abusive and a pseudoscientific intervention, not based on attachment theory or research, that has resulted in tragic
outcomes for children including at least six documented child fatalities.[6] In 2006, the American Professional
Society on the Abuse of Children (APSAC) Task Force reported on the subjects of attachment therapy, reactive
attachment disorder, and attachment problems and laid down guidelines for the future diagnosis and treatment of
attachment disorders.[1] The APSAC Task Force was largely critical of Attachment Therapy's theoretical base,
practices, claims to an evidence base, non-specific symptoms lists published on the internet, claims that traditional
treatments do not work and dire predictions for the future of children who do not receive attachment therapy.
"Although focused primarily on specific attachment therapy techniques, the controversy also extends to the theories,
diagnoses, diagnostic practices, beliefs, and social group norms supporting these techniques, and to the patient
recruitment and advertising practices used by their proponents."[3] In 2007, Scott Lilienfeld included holding therapy
as one of the potentially harmful therapies (PHT's) at level 1 in his Psychological Science review.[72] Describing it as
"unfortunately" referred to as "attachment therapy", Mary Dozier and Michael Rutter consider it critical to
differentiate it from treatments derived from attachment theory.[73] A mistaken association between attachment
therapy and attachment theory may have resulted in a relatively unenthusiastic view towards the latter among some
practitioners despite its relatively profound lines of research in the field of socioemotional development.[5]
Claims
According to the APSAC Task Force, proponents of attachment therapy commonly assert that their therapies alone
are effective for attachment-disordered children and that traditional treatments are ineffective or harmful.[15] The
APSAC Task Force expressed concern over claims by therapies to be "evidence-based", or the only evidence-based
therapy, when the Task Force found no credible evidence base for any such therapy so advertised.[74] Nor did it
accept more recent claims to evidence base in its November 2006 Reply.[56]
Two approaches on which published studies have been undertaken are holding therapy[75] and dyadic developmental
psychotherapy.[76] Each of these non-randomized studies concluded that the treatment method studied was effective.
Both the APSAC Task Force and Prior and Glaser cite and criticize the one published study on holding therapy
undertaken by Myeroff et al., which "purports to be an evaluation of holding therapy".[75] [77] [78] This study covers
the "across the lap" approach, described as "not restraint" by Howe and Fearnley but "being held whilst unable to
gain release."[79] Prior and Glaser state that although the Myeroff study claims it is based on attachment theory, the
theoretical basis for the treatment is in fact Zaslow.[34]
Dyadic developmental psychotherapy was developed by psychologist Daniel Hughes, described by the Task Force as
a "leading attachment therapist". Hughes' website gave a list of attachment therapy techniques, repeated by the
APSAC Task Force from an earlier website, which he stated do not or should not form part of dyadic developmental
psychotherapy, which the Task Force took as a description of attachment therapy techniques.[80] [81] Two studies on
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Attachment therapy
dyadic developmental psychotherapy have been published by Dr. Becker-Weidman, the second being a four-year
follow up of the first.[76] Prior and Glaser state Hughes' therapy reads as good therapy for abused and neglected
children, though with "little application of attachment theory", but the advocacy group ACT and the Task Force
place Hughes within the attachment therapy paradigm.[56] [82] [83]
In 2004, Saunders, Berliner and Hanson developed a system of categories for social work interventions which has
proved somewhat controversial.[84] [85] In their first analysis, holding therapy was placed in Category 6 as a
"Concerning treatment". In 2006 Craven and Lee classified 18 studies in a literature review under the Saunders,
Berliner & Hanson system.[86] They considered both dyadic developmental psychotherapy and holding therapy.[75]
[87]
They placed both in Category 3 as "Supported and acceptable". This categorization by Craven and Lee has been
criticized as unduly favorable,[88] a point to which Craven and Lee responded by arguments in support of holding
therapy.[89] Both Myeroff et al.'s study and Becker-Weidman's first study (published after the main Report) were
examined in the Task Force's November 2006 Reply to Letters and were criticized as to their methodology.
Becker-Weidman's study was described by the Task Force as "an important first step toward learning the facts about
DDP outcomes" but falling far short of the criteria necessary to constitute an evidence base.[56]
Some studies are still being undertaken on coercive therapies. A nonrandomized, before-and-after 2006 pilot study
by Welch (the progenitor of "holding time") et al. on Welch's "prolonged parent-child embrace therapy" was
conducted on children with a range of diagnoses for behavioral disorders and claimed to show significant
improvement.[10]
In March 2007, attachment therapy was placed on a list of treatments that have the potential to cause harm to clients
in the APS journal, Perspectives on Psychological Science. Concern was expressed about methods that involve
holding and restraint, and the lack of randomized, controlled experiments showing the effectiveness of the
treatment.[72]
Cases
There have been a number of cases of serious harm to children in which controversial attachment therapy techniques,
theories or belief systems have been implicated. An estimated six children have died as a consequence of the more
coercive forms of such treatments or the application of the accompanying parenting techniques.[4] [90]
Andrea Swenson, 1990; a 13-year-old adopted girl undergoing attachment therapy at The Attachment Center,
Evergreen. She was placed with "therapeutic foster parents". When the insurance company refused to continue to
pay for her treatment, the adoptive parents were asked to allow the foster parents to adopt Andrea so that a fresh
claim could be made. Andrea, having asked her foster parents what would happen if she took an overdose of
drugs or slit her wrist, and been told she would die, took an overdose of aspirin. She was violently ill during the
night and was incoherent, breathing heavily and still vomiting in the morning. Nevertheless the foster parents
went bowling, leaving her alone. A visitor found her dead in the hallway. The suit was settled out of court.[91] [92]
Lucas Ciambrone, 1995; a seven-year-old adopted boy who was starved, beaten, bitten and forced to sleep in a
stripped bathroom. At the post-mortem he was found to have 200 bruises and five old broken ribs. The adoptive
mother was convicted as the abuser and the adoptive father of being aware but doing nothing to prevent it or seek
help. Foster Cline gave evidence for both parents claiming Lucas suffered from reactive attachment disorder and
that living with such a child was like living "in a situation with the same psychic pressures as those experienced in
a concentration camp or cult" and that the parents were in no way responsible for the genesis of Lucas' alleged
difficult behaviors. No violent or angry behaviors were reported at school.[93] [94]
David Polreis, 1996; a two-year-old adopted boy who was beaten to death by his adoptive mother. Foster Cline
gave evidence for the mother claiming David suffered from reactive attachment disorder. The adoptive mother,
supported by attachment therapists practising the Evergreen model, claimed he had beaten himself to death as a
consequence of his attachment disorder.[20] (She subsequently claimed he had attacked her and she had acted in
self defense). David had been diagnosed with attachment disorder by an attachment therapist and was undergoing
210
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treatment and accompanying attachment parenting techniques. Mourners at the funeral were asked to contribute to
The Attachment Center.[95] [96] [97]
Krystal Tibbets, 1997; a three-year-old adopted child who was killed by her adoptive father using holding therapy
techniques he claimed had been taught to him by an attachment therapy center. This was denied by the therapist
and the adoptive mother. He lay on top of Krystal, a technique known as "compression therapy", and pushed his
fist into her abdomen to release "visceral rage" and to enforce bonding. When she stopped screaming and
struggling he believed she had "shut down" as a form of "resistance". After his release from a five-year prison
sentence the adoptive father campaigned to have attachment therapy banned.[98] [99]
Candace Newmaker, 2000; a ten-year-old adopted girl who was killed by asphyxiation during a rebirthing session
used as part of a two week attachment therapy "intensive". The two attachment therapists, Connell Watkins
(formerly of The Attachment Center, Evergreen) and Julie Ponder were each sentenced to 16years imprisonment
for their part in the therapy during which Candace was wrapped in blankets and required to struggle to be reborn,
against the weight of several adults. Her inability to struggle out was interpreted as "resistance". Her adoptive
mother and the "therapeutic foster parents" with whom she had been placed received lesser penalties.[66] [100]
Watkins was released on parole in August 2008 after serving approximately 7 years of her sentence.[101]
Logan Marr, 2001; a five-year-old child who had been fostered by a caseworker. While having a tantrum, the
screaming girl was buckled into a highchair, wrapped with duct tape, including over her mouth, and left in a
basement where she suffocated. The foster mother claimed to have used some attachment therapy ideas and
techniques she had picked up when working as a caseworker.[102] [103]
Cassandra Killpack, 2002; a four-year-old adopted child who died from complications of hyponatremia secondary
to water intoxication. This apparently occurred when she was restrained in a chair and forced to drink excessive
amounts of water by her adoptive parents as part of an "attachment-based" treatment using techniques they
claimed had been taught to them at the attachment therapy center where Cassandra was undergoing treatment. It
appears this was a punishment for having drunk some of her sister's drink.[104] [105] [106] [107]
Gravelles, 2003; 11 special needs children adopted by Michael and Sharon Gravelle. Many of the 11 children
slept in cages. The case also involved allegations of extreme control over food and toileting and severe
punishments for disobedience. The children were home-schooled. Some of the children underwent holding
therapy from their attachment therapist and the adoptive parents used accompanying attachment therapy parenting
techniques at home. The adoptive parents and therapist were prosecuted and convicted in 2003.[108] [109] [110] [111]
Vasquez, 2007: four adopted children, three of whom were kept in cages, fed limited diets, and permitted only
primitive sanitary facilities. The fourth child, the favorite, was given medication to delay puberty. The adoptive
mother received a prison sentence of less than a year and her parental rights were terminated in 2007. There was
no therapist in this case but the adoptive mother claimed that three of her four adopted children had reactive
attachment disorder.[112] [113]
Notes
[1]
[2]
[3]
[4]
Task Force Report, Chaffin et al. p. 83

O'Connor TG, Zeanah CH (2003), "Attachment disorders: assessment strategies and treatment approaches" (http:/ / www. informaworld.
com/ openurl?genre=article& doi=10. 1080/ 14616730310001593974& magic=pubmed), Attach Hum Dev 5 (3): 22344,
doi:10.1080/14616730310001593974, PMID12944216,
[5] Ziv Y (2005), "Attachment-Based Intervention programs: Implications for Attachment Theory and Research", in Berlin LJ, Ziv Y,
Amaya-Jackson L, Greenberg MT, Enhancing Early Attachments. Theory, Research, Intervention and Policy, Duke series in child
development and public policy, Guilford Press, pp.63, ISBN1-59385-470-6
[6] Berlin LJ et al. (2005), "Preface", in Berlin LJ, Ziv Y, Amaya-Jackson L, Greenberg MT, Enhancing Early Attachments: Theory, Research,
Intervention and Policy, Duke series in child development and public policy, Guilford Press, pp.xvii, ISBN1-59385-470-6
[7] Task Force Report, Chaffin et al.
211
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[8] (PDF) ATTACh White paper on coercion (http:/ / www. attach. org/ WhitePaper. pdf), ATTACh, 2007, , retrieved 2008-03-16
[9] Welch MG (September 1989), Holding Time: How to Eliminate Conflict, Temper Tantrums, and Sibling Rivalry and Raise Happy, Loving,
Successful Children, foreword by Niko Tinbergen, New York: Simon & Schuster, ISBN0671688782
[10] Welch MG, Northrup RS, Welch-Horan TB, Ludwig RJ, Austin CL, Jacobson JS (2006), "Outcomes of Prolonged Parent-Child Embrace
Therapy among 102 children with behavioral disorders." (http:/ / linkinghub. elsevier. com/ retrieve/ pii/ S1744-3881(05)00097-6),
Complement Ther Clin Pract 12 (1): 312, doi:10.1016/j.ctcp.2005.09.004, PMID16401524,
[11] Mercer J (2005), "Coercive Restraint Therapies: A dangerous alternative mental health intervention", Medscape General Medicine 7 (3)
[12] Advocates for Children in therapy, What is Attachment Therapy (http:/ / www. childrenintherapy. org/ proponents/ cline. html), , retrieved
2008-09-17, "Z-therapy, rage-reduction therapy, Theraplay, holding therapy, attachment holding therapy, attachment disorder therapy,
holding time, cuddle time, gentle containment, holding-nurturing process, emotional shuttling, direct synchronous bonding, breakthrough
synchronous bonding, therapeutic parenting, dynamic attachment therapy, humanistic attachment therapy, corrective attachment therapy,
developmental attachment therapy, dyadic attachment therapy, dyadic developmental psychotherapy, dyadic support environment, affective
attunement"
[13] Advocates for Children in therapy, What is Attachment Therapy (http:/ / www. childrenintherapy. org/ essays/ index. html), , retrieved
2008-09-17
[14] Speltz ML (2002), "Description, History and Critique of Corrective Attachment Therapy" (http:/ / www. kidscomefirst. info/ Speltz. pdf)
(PDF), The APSAC Advisor 14 (3): 48, , retrieved 2008-03-16
[15] Task Force Report, Chaffin et al. p. 78
[16] Advocates for Children in therapy, Abusive Techniques (http:/ / www. childrenintherapy. org/ essays/ abuses. html), , retrieved 2008-09-17
[17] Perry B, Szalavitz M (2006), The Boy Who Was Raised as a Dog, Philadelphia: Basic Books, pp.160169, ISBN9780465056538
[18] Thomas N (2000), "Parenting children with attachment disorders", in Levy TM, Handbook of attachment interventions, San Diego, CA:
Academic
[19] Cline FW (1992), Hope for High Risk and Rage Filled Children: Reactive Attachment Disorder: Theory and Intrusive Therapy, Golden,
CO: EC Publications, ISBN0963172808
[20] Stryker R (2010), The Road to Evergreen: Adoption, Attachment Therapy, and the Promise of Family, Ithaca, London: Cornell University
press, ISBN9780801446870
[21] Hage D (1997), "Holding therapy: Harmful? Or rather beneficial!", Roots and Wings Adoption Magazine
[22] Mercer et al. pps. 98105
[23] Mercer et al. pps. 7579, 195
[24] Haugaard JJ (2004), "Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been
severely maltreated: introduction", Child Maltreat 9 (2): 12330, doi:10.1177/1077559504264304, PMID15104880
[25] Nichols M, Lacher D, May J (2002), Parenting with stories: creating a foundation of attachment for parenting your child, Deephaven, MN:
Family Attachment Counseling Center, ISBN0974602906
[27] Prior and Glaser p. 23132
[28] Boris NW, Zeanah CH, Work Group on Quality Issues (2005), "Practice parameter for the assessment and treatment of children and
adolescents with reactive attachment disorder of infancy and early childhood" (http:/ / www. aacap. org/ galleries/ PracticeParameters/ rad.
pdf) (PDF), J Am Acad Child Adolesc Psychiatry 44 (11): 120619, doi:10.1097/01.chi.0000177056.41655.ce, PMID16239871, , retrieved
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[30] Mercer et al. p. 92
[32] Randolph E (2001), Broken hearts, wounded minds, Evergreen, CO: RFR Publications
[33] O'Connor and Nilsen p. 316
[35] Dozier M (September 2003), "Attachment-based treatment for vulnerable children" (http:/ / www. informaworld. com/
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[37] Task Force Report, Chaffin et al. pp. 79, 8283
[40] Zaslow R, Menta M (1975), The psychology of the Z-process: Attachment and activity, San Jose, CA: San Jose University Press
[41] Task Force Report, Chaffin et al., pp.8384, "Many of the controversial attachment therapies have promulgated quite broad and nonspecific
lists of symptoms purported to indicate when a child has an attachment disorder. For example, Reber (1996) provided a table that lists
"common symptoms of RAD." The list includes problems or symptoms across multiple domains (social, emotional, behavioral and
developmental) and ranges from DSM-IV criteria for RAD (e.g., superficial interactions with others, indiscriminate affection toward strangers,
and lack of affection toward parents), to nonspecific behavior problems including destructive behaviors; developmental lags; refusal to make
eye contact; cruelty to animals and siblings; lack of cause and effect thinking; preoccupation with fire, blood, and gore; poor peer
212
Attachment therapy
relationships; stealing; lying; lack of a conscience; persistent nonsense questions or incessant chatter; poor impulse control; abnormal speech
patterns; fighting for control over everything; and hoarding or gorging on food. Others have promulgated checklists that suggest that among
infants, "prefers dad to mom" or "wants to hold the bottle as soon as possible" are indicative of attachment problems (Buenning, 1999).
Clearly, these lists of nonspecific problems extend far beyond the diagnostic criteria for RAD and beyond attachment relationship problems in
general. These types of lists are so nonspecific that high rates of false-positive diagnoses are virtually certain. Posting these types of lists on
internet sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment
disorders"
[42] Randolph EM (1996), Randolph Attachment Disorder Questionnaire, Institute for Attachment, Evergreen CO
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conclusion is that the RADQ has limited usefulness due to its lack of specificity with implications for treatment of children in foster care"
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[74] "Some proponents have claimed that research exists that supports their methods, or that their methods are evidence based, or are even the
sole evidence-based approach in existence, yet these proponents provide no citations to credible scientific research sufficient to support these
claims (Becker-Weidman, n.d.-b). This Task Force was unable to locate any methodologically adequate clinical trials in the published
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References
(APSAC Task Force report), Chaffin M, Hanson R, Saunders BE, et al. (2006), "Report of the APSAC Task
Force on attachment therapy, reactive attachment disorder, and attachment problems.", Child Maltreat 11 (1):
7689, doi:10.1177/1077559505283699, PMID16382093
Mercer J, Sarner L, Rosa L (2003), Attachment Therapy on Trial: The Torture and Death of Candace Newmaker,
Praeger, ISBN0275976750
O'Connor TG, Nilsen WJ (2005), "Models versus Metaphors in Translating Attachment Theory to the Clinic and
Community", in Berlin LJ, Ziv Y, Amaya-Jackson L, Greenberg MT, Enhancing Early Attachments: Theory,
Research, Intervention and Policy, Duke series in child development and public policy, Guilford Press,
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External links
Association for Treatment and Training in the Attachment of Children (ATTACh) (http://www.attach.org)
Self-described as "an international coalition of professionals and families dedicated to helping those with
attachment difficulties by sharing our knowledge, talents and resources"
(http://www.childrenintherapy.org/index.html) Child advocacy group opposing attachment therapy
"Be Wary of Attachment Therapy" (http://www.quackwatch.org/01QuackeryRelatedTopics/at.html) from
Quackwatch medical watchdog website
"Underground network moves children from home to home" (http://www.usatoday.com/news/nation/
2006-01-18-swapping-children_x.htm) Koch W. USAtoday article.
ebm-first.com (http://www.ebm-first.com/?cat=67) - evidence-based medicine campaign group.
kidscomefirst (http://www.kidscomefirst.info/) anti-attachment therapy source site
Attachment therapy page from Coalition Against Institutionalized Child Abuse (CAICA) (http://www.caica.
org/Attachment Disorder Main.htm)
2008 investigation into death of a foster child (http://www.dleg.state.mi.us/fhs/brs/reports/
CP140201012_SIR_2008C0105024.pdf)
Attachment disorder
Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships
arising from a failure to form normal attachments to primary care giving figures in early childhood, resulting in
problematic social expectations and behaviors. Such a failure would result from unusual early experiences of neglect,
abuse, abrupt separation from caregivers after about six months but before about three years, frequent change of
caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts. A
problematic history of social relationships occurring after about age three may be distressing to a child, but does not
result in attachment disorder.
The term attachment disorder is most often used to describe emotional and behavioral problems of young children,
but is sometimes applied to school-age children or even to adults. The specific difficulties implied depend on the age
of the individual being assessed, and a child's attachment-related behaviors may be very different with one familiar
adult than with another, suggesting that the disorder is within the relationship and interactions of the two people
rather than an aspect of one or the other personality.[1] No list of symptoms can legitimately be presented but
generally the term attachment disorder refers to the absence or distortion of age appropriate social behaviors with
adults. For example, in a toddler, attachment-disordered behavior could include a failure to stay near familiar adults
in a strange environment or to be comforted by contact with a familiar person, whereas in a six-year-old
attachment-disordered behavior might involve excessive friendliness and inappropriate approaches to strangers.
There are currently two main areas of theory and practice relating to the definition and diagnosis of attachment
disorder, and considerable discussion about a broader definition altogether. The first main area is based on scientific
enquiry, is found in academic journals and books and pays close attention to attachment theory. It is described in
ICD-10 as reactive attachment disorder, or "RAD" for the inhibited form, and disinhibited attachment disorder, or
"DAD" for the disinhibited form. In DSM-IV-TR both comparable inhibited and disinhibited types are called
reactive attachment disorder or "RAD".[2]
The second area is controversial and considered pseudoscientific.[3] It is found in clinical practice, on websites and in
books and publications, but has little or no evidence base. It makes controversial claims relating to a basis in
attachment theory.[4] The use of these controversial diagnoses of attachment disorder is linked to the use of
pseudoscientific attachment therapies to treat them.[2] [3]
216
Attachment disorder
Some authors have suggested that attachment, as an aspect of emotional development, is better assessed along a
spectrum than considered to fall into two non-overlapping categories. This spectrum would have at one end the
characteristics called secure attachment; midway along the range of disturbance would be insecure or other
undesirable attachment styles; at the other extreme would be non-attachment.[5] Agreement has not yet been reached
with respect to diagnostic criteria.[6]
Finally, the term is also sometimes used to cover difficulties arising in relation to various attachment styles which
may not be disorders in the clinical sense.
Attachment and attachment disorder

Attachment theory is primarily an evolutionary and ethological theory. In relation to infants, it primarily consists of
proximity seeking to an attachment figure in the face of threat, for the purpose of survival.[7] Although an attachment
is a "tie" it is not synonymous with love and affection although they often go together and a healthy attachment is
considered to be an important foundation of all subsequent relationships. Infants become attached to adults who are
sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some
time. Parental responses lead to the development of patterns of attachment which in turn lead to 'internal working
models' which will guide the individual's feelings, thoughts and expectations in later relationships.[8]
In the clinical sense, a disorder is a condition requiring treatment as opposed to risk factors for subsequent
disorders.[9] There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there
is general agreement that such disorders only arise following early adverse caregiving experiences. Reactive
attachment disorder indicates the absence of either or both the main aspects of proximity seeking to an identified
attachment figure. This can occur either in institutions, or with repeated changes of caregiver, or from extremely
neglectful primary caregivers who show persistent disregard for the child's basic attachment needs after the age of 6
months. Current official classifications of RAD under DSM-IV-TR and ICD-10 are largely based on this
understanding of the nature of attachment.
The words attachment style or pattern refer to the various types of attachment arising from early care experiences,
called secure, anxious-ambivalent, anxious-avoidant, (all organized), and disorganized. Some of these styles are
more problematic than others, and, although they are not disorders in the clinical sense, are sometimes discussed
under the term 'attachment disorder'.
Discussion of the disorganized attachment style sometimes includes this style under the rubric of attachment
disorders because disorganized attachment is seen as the beginning of a developmental trajectory that will take the
individual ever further from the normal range, culminating in actual disorders of thought, behavior, or mood.[10]
Early intervention for disorganized attachment, or other problematic styles, is directed toward changing the
trajectory of development to provide a better outcome later in the person's life.
Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder,
namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These
classifications consider that a disorder is a variation that requires treatment rather than an individual difference
within the normal range.[11]
217
Attachment disorder
Classification
ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited Disorder of
Childhood, less well known as DAD. DSM-IV-TR also describes Reactive Attachment Disorder of Infancy or Early
Childhood. It divides this into two subtypes, Inhibited Type and Disinhibited Type, both known as RAD. The two
classifications are similar and both include:
markedly disturbed and developmentally inappropriate social relatedness in most contexts,
the disturbance is not accounted for solely by developmental delay and does not meet the criteria for Pervasive
Developmental Disorder,
onset before 5 years of age,
requires a history of significant neglect, and
implicit lack of identifiable, preferred attachment figure.
ICD-10 includes in its diagnosis psychological and physical abuse and injury in addition to neglect. This is
somewhat controversial, being a commission rather than omission and because abuse of itself does not lead to
attachment disorder.
The inhibited form is described as "a failure to initiate or respond...to most social interactions, as manifest by
excessively inhibited responses" and such infants do not seek and accept comfort at times of threat, alarm or distress,
thus failing to maintain 'proximity', an essential element of attachment behavior. The disinhibited form shows
"indiscriminate sociability...excessive familiarity with relative strangers" (DSM-IV-TR) and therefore a lack of
'specificity', the second basic element of attachment behavior. The ICD-10 descriptions are comparable.
'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in the same child. The
inhibited form has a greater tendency to ameliorate with an appropriate caregiver whilst the disinhibited form is more
enduring.[12]
While RAD is likely to occur following neglectful and abusive childcare, there should be no automatic diagnosis on
this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect.
Abuse can occur alongside the required factors but on its own does not explain attachment disorder. Experiences of
abuse are associated with the development of disorganised attachment, in which the child prefers a familiar
caregiver, but responds to that person in an unpredictable and somewhat bizarre way. Within official classifications,
attachment disorganization is a risk factor but not in itself an attachment disorder. Further although attachment
disorders tend to occur in the context of some institutions, repeated changes of primary caregiver or extremely
neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, not
all children raised in these conditions develop an attachment disorder.[13]
Boris and Zeanah's typology

Many leading attachment theorists, such as Zeanah and Leiberman, have recognized the limitations of the
DSM-IV-TR and ICD-10 criteria and proposed broader diagnostic criteria. There is as yet no official consensus on
these criteria. The APSAC Taskforce recognised in its recommendations that "attachment problems extending
beyond RAD, are a real and appropriate concern for professionals working with children", and set out
recommendations for assessment.[14]
Boris and Zeanah (1999),[15] have offered an approach to attachment disorders that considers cases where children
have had no opportunity to form an attachment, those where there is a distorted relationship, and those where an
existing attachment has been abruptly disrupted. This would significantly extend the definition beyond the ICD-10
and DSM-IV-TR definitions because those definitions are limited to situations where the child has no attachment or
no attachment to a specified attachment figure.
Boris and Zeanah use the term "disorder of attachment" to indicate a situation in which a young child has no
preferred adult caregiver. Such children may be indiscriminately sociable and approach all adults, whether familiar
218
Attachment disorder
or not; alternatively, they may be emotionally withdrawn and fail to seek comfort from anyone. This type of
attachment problem is parallel to Reactive Attachment Disorder as defined in DSM and ICD in its inhibited and
disinhibited forms as described above.
Boris and Zeanah also describe a condition they term "secure base distortion". In this situation, the child has a
preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually
exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively
compliant, or may show role reversals in which they care for or punish the adult.
The third type of disorder discussed by Boris and Zeanah is termed "disrupted attachment". This type of problem,
which is not covered under other approaches to disordered attachment, results from an abrupt separation or loss of a
familiar caregiver to whom attachment has developed. The young child's reaction to such a loss is parallel to the
grief reaction of an older person, with progressive changes from protest (crying and searching) to despair, sadness,
and withdrawal from communication or play, and finally detachment from the original relationship and recovery of
social and play activities.
Most recently, Daniel Schechter and Erica Willheim have shown a relationship between maternal violence-related
posttraumatic stress disorder and secure base distortion (see above) which is characterized by child recklessness,
separation anxiety, hypervigilance, and role-reversal.[16]
Problems of attachment style

The majority of 12-month-old children can tolerate brief separations from familiar caregivers and are quickly
comforted when the caregivers return. These children also use familiar people as a "secure base" and return to them
periodically when exploring a new situation. Such children are said to have a secure attachment style, and
characteristically continue to develop well both cognitively and emotionally.
Smaller numbers of children show less positive development at age 12 months. Their less desirable attachment styles
may be predictors of poor later social development. Although these children's behavior at 12 months is not a serious
problem, they appear to be on developmental trajectories that will end in poor social skills and relationships. Because
attachment styles may serve as predictors of later development, it may be appropriate to think of certain attachment
styles as part of the range of attachment disorders.
Insecure attachment styles in toddlers involve unusual reunions after separation from a familiar person. The children
may snub the returning caregiver, or may go to the person but then resist being picked up. These children are more
likely to have later social problems with peers and teachers, but some of them spontaneously develop better ways of
interacting with other people.
A small group of toddlers show a distressing way of reuniting after a separation. Called a disorganized/disoriented
style, this reunion pattern can involve looking dazed or frightened, freezing in place, backing toward the caregiver or
approaching with head sharply averted, or showing other behaviors that seem to imply fearfulness of the person who
is being sought.[17] Disorganized attachment has been considered a major risk factor for child psychopathology, as it
appears to interfere with regulation or tolerance of negative emotions and may thus foster aggressive behavior.[18]
Disorganized patterns of attachment have the strongest links to concurrent and subsequent psychopathology, and
considerable research has demonstrated both within-the-child and environmental correlates of disorganized
attachment.[19]
219
Attachment disorder
Diagnosis
Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation
procedure (Mary Ainsworth),[20] [21] [22] the separation and reunion procedure and the Preschool Assessment of
Attachment ("PAA"),[23] the Observational Record of the Caregiving Environment ("ORCE")[24] and the Attachment
Q-sort ("AQ-sort").[25] More recent research also uses the Disturbances of Attachment Interview or "DAI" developed
by Smyke and Zeanah, (1999).[26] This is a semi-structured interview designed to be administered by clinicians to
caregivers. It covers 12 items, namely having a discriminated, preferred adult, seeking comfort when distressed,
responding to comfort when offered, social and emotional reciprocity, emotional regulation, checking back after
venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative strangers,
self endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal.
Treatment
There are a variety of mainstream prevention programs and treatment approaches for attachment disorder,
attachment problems and moods or behaviors considered to be potential problems within the context of attachment
theory. All such approaches for infants and younger children concentrate on increasing the responsiveness and
sensitivity of the caregiver, or if that is not possible, changing the caregiver.[27] [28] [29] Such approaches include
'Watch, wait and wonder,'[30] manipulation of sensitive responsiveness,[31] [32] modified 'Interaction Guidance,'.[33]
'Preschool Parent Psychotherapy,'.[34] 'Circle of Security',[35] [36] Attachment and Biobehavioral Catch-up (ABC),[37]
the New Orleans Intervention,[38] [39] [40] and Parent-Child psychotherapy.[41] Other known treatment methods
include Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by
Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders[42] Some
of these approaches, such as that suggested by Dozier, consider the attachment status of the adult caregiver to play an
important role in the development of the emotional connection between adult and child. This includes foster parents,
as children with poor attachment experiences often do not elicit appropriate caregiver responses from their
attachment behaviors despite 'normative' care.[37]
Treatment for reactive attachment disorder for children usually involves a mix of therapy, counseling, and parenting
education. These must be designed to make sure the child has a safe environment to live in and to develop positive
interactions with caregivers and improves their relationships with their peers.
Medication can be used as a way to treat similar conditions, like depression, anxiety, or hyperactivity; however, there
is no quick fix for treating reactive attachment disorder. A pediatrician may recommend a treatment plan. For
example, a mix of family therapy, individual psychological counseling, play therapy, special education services and
parenting skills classes. .[43]
Possible mechanisms
One study has reported a connection between a specific genetic marker and disorganized attachment (not RAD)
associated with problems of parenting.[44] Another author has compared atypical social behavior in genetic
conditions such as Williams syndrome with behaviors symptomatic of RAD.[45]
Typical attachment development begins with unlearned infant reactions to social signals from caregivers. The ability
to send and receive social communications through facial expressions, gestures and voice develops with social
experience by seven to nine months. This makes it possible for an infant to interpret messages of calm or alarm from
face or voice. At about eight months, infants typically begin to respond with fear to unfamiliar or startling situations,
and to look to the faces of familiar caregivers for information that either justifies or soothes their fear. This
developmental combination of social skills and the emergence of fear reactions results in attachment behavior such
as proximity-seeking, if a familiar, sensitive, responsive, and cooperative adult is available. Further developments in
attachment, such as negotiation of separation in the toddler and preschool period, depend on factors such as the
220
Attachment disorder
caregiver's interaction style and ability to understand the child's emotional communications.[46]
With insensitive or unresponsive caregivers, or frequent changes, an infant may have few experiences that encourage
proximity seeking to a familiar person. An infant who experiences fear but who cannot find comforting information
in an adult's face and voice may develop atypical ways of coping with fearfulness such as the maintenance of
distance from adults, or the seeking of proximity to all adults. These symptoms accord with the DSM criteria for
reactive attachment disorder.[47] Either of these behavior patterns may create a developmental trajectory leading ever
farther from typical attachment processes such as the development of an internal working model of social
relationships that facilitates both the giving and the receiving of care from others.[48] [49]
Atypical development of fearfulness, with a constitutional tendency either to excessive or inadequate fear reactions,
might be necessary before an infant is vulnerable to the effects of poor attachment experiences.[50]
Alternatively, the two variations of RAD may develop from the same inability to develop "stranger-wariness" due to
inadequate care. Appropriate fear responses may only be able to develop after an infant has first begun to form a
selective attachment. An infant who is not in a position do this cannot afford not to show interest in any person as
they may be potential attachment figures. Faced with a swift succession of carers the child may have no opportunity
to form a selective attachment until the possible biological-determined sensitive period for developing
stranger-wariness has passed. It is thought this process may lead to the disinhibited form.[51]
In the inhibited form infants behave as if their attachment system has been "switched off". However the innate
capacity for attachment behavior cannot be lost. This may explain why children diagnosed with the inhibited form of
RAD from institutions almost invariably go on to show formation of attachment behavior to good carers. However
children who suffer the inhibited form as a consequence of neglect and frequent changes of caregiver continue to
show the inhibited form for far longer when placed in families.[51]
Additionally, the development of Theory of Mind may play a role in emotional development. Theory of Mind is the
ability to know that the experience of knowledge and intention lies behind human actions such as facial expressions.
Although it is reported that very young infants respond differently to humans and objects, Theory of Mind develops
relatively gradually and possibly results from predictable interactions with adults. However, some ability of this kind
must be in place before mutual communication through gaze or other gesture can occur, as it does by seven to nine
months. Some neurodevelopmental disorders, such as autism, have been attributed to the absence of the mental
functions that underlie Theory of Mind. It is possible that the congenital absence of this ability, or the lack of
experiences with caregivers who communicate in a predictable fashion, could underlie the development of reactive
attachment disorder.[52] [53]
Pseudoscientific diagnoses and treatment

In the absence of officially recognized diagnostic criteria, and beyond the ambit of the discourse on a broader set of
criteria discussed above, the term attachment disorder has been increasingly used by some clinicians to refer to a
broader set of children whose behavior may be affected by lack of a primary attachment figure, a seriously unhealthy
attachment relationship with a primary caregiver, or a disrupted attachment relationship.[54] Although there are no
studies examining diagnostic accuracy, concern is expressed as to the potential for over-diagnosis based on broad
checklists and 'snapshots'.[55] This form of therapy, including diagnosis and accompanying parenting techniques, is
scientifically unvalidated and is not considered to be part of mainstream psychology or, despite its name, to be based
on attachment theory, with which it is considered incompatible.[56] [57] It has been described as potentially abusive
and a pseudoscientific intervention, that has resulted in tragic outcomes for children.[3]
A common feature of this form of diagnosis within attachment therapy is the use of extensive lists of "symptoms"
which include many behaviours that are likely to be a consequence of neglect or abuse, but are not related to
attachment, or not related to any clinical disorder at all. Such lists have been described as "wildly inclusive".[58] The
APSAC Taskforce (2006) gives examples of such lists ranging across multiple domains from some elements within
the DSM-IV criteria to entirely non-specific behavior such as developmental lags, destructive behaviors, refusal to
221
Attachment disorder
make eye contact, cruelty to animals and siblings, lack of cause and effect thinking, preoccupation with fire, blood
and gore, poor peer relationships, stealing, lying, lack of a conscience, persistent nonsense questions or incessant
chatter, poor impulse control, abnormal speech patterns, fighting for control over everything, and hoarding or
gorging on food. Some checklists suggest that among infants, prefers dad to mom or wants to hold the bottle as
soon as possible are indicative of attachment problems. The APSAC Taskforce expresses concern that high rates of
false positive diagnoses are virtually certain and that posting these types of lists on web sites that also serve as
marketing tools may lead many parents or others to conclude inaccurately that their children have attachment
disorders."[59]
There is also a considerable variety of treatments for alleged attachment disorders diagnosed on the controversial
alternative basis outlined above, popularly known as attachment therapy. These therapies have little or no evidence
base and vary from talking or play therapies to more extreme forms of physical and coercive techniques, of which
the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. In general these therapies
are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers.
Critics maintain these therapies are not based on an accepted version of attachment theory.[60] The theoretical base is
broadly a combination of regression and catharsis, accompanied by parenting methods which emphasise obedience
and parental control.[61] These therapies concentrate on changing the child rather than the caregiver.[62] An estimated
six children have died as a consequence of the more coercive forms of such treatments and the application of the
accompanying parenting techniques.[63] [64] [65]
Two of the most well-known cases are those of Candace Newmaker in 2001 and the Gravelles in 2003 through 2005.
Following the associated publicity, some advocates of attachment therapy began to alter views and practices to be
less potentially dangerous to children. This change may have been hastened by the publication of a Task Force
Report on the subject in January 2006, commissioned by the American Professional Society on the Abuse of
Children (APSAC) which was largely critical of attachment therapy, although these practices continue.[66] In April
2007, ATTACh, an organisation originally set up by attachment therapists, formally adopted a White Paper stating
its unequivocal opposition to the use of coercive practices in therapy and parenting.[67]
Notes
[1] Zeanah, 2005
[2] Chaffin et al. (2006) p78
[3] Berlin LJ et al. (2005). "Preface". In Berlin LJ, Ziv Y, Amaya-Jackson L, Greenberg MT. Enhancing Early Attachments: Theory, Research,
Intervention and Policy. Duke series in child development and public policy. Guilford Press. pp.xvii. ISBN1-59385-470-6.
[4] Prior & Glaser p 183
[5] O'Connor & Zeanah, (2003)
[6] Chaffin et al. p. (2006)
[7] Bowlby (1970) p 181
[8] Bretherton & Munholland (1999) p 89
[9] AACAP 2005, p1208
[10] Levy K.N. et al. (2005)
[11] Prior & Glaser (2006) p 223
[12] Prior & Glaser 2006, p. 220-221.
[13] Prior & Glaser (2006) p218-219
[14] Chaffin (2006) p 86
[15] Boris & Zeannah (1999)
[16] Schechter DS, Willheim E (2009). Disturbances of attachment and parental psychopathology in early childhood. Infant and Early Childhood
Mental Health Issue. Child and Adolescent Psychiatry Clinics of North America, 18(3), 665-687.
[17] Mercer, J (2006) p 107
[18] VanIJzendoorn & Bakermans-Kranenburg (2003)
[19] Zeanah et al. (2003)
[20] Ainsworth (1978),
[21] Main & Solomon (1986), pp.95-124.
[22] Main & Solomon (1990), pp. 121-160.
222
Attachment disorder
[23] Crittenden (1992)
[24] National Institute of Child Health and Human Development(1996)
[25] Waters and Deane (1985)
[26] Smyke and Zeanah (1999)
[27] Prior & Glaser (2006), p. 231.
[28] AACAP (2005) p. 17-18.
[29] BakermansKranenburg et al. (2003) A meta-analysis of early interventions.
[30] Cohen et al. (1999)
[31] van den Boom (1994)
[32] van den Boom (1995)
[33] Benoit et al. (2001)
[34] Toth et al. (2002)
[35] Marvin et al. (2002)
[36] Cooper et al. (2005)
[37] Dozier et al. (2005)
[38] Larrieu & Zeanah (1998)
[39] Larrieu & Zeannah (2004)
[40] Zeannah & Smyke (2005)
[41] Leiberman et al. (2000), p. 432.
[42] Interdisciplinary Council on Developmental & Learning Disorders. (2007). Dir/floortime model (http:/ / www. icdl. com/ dirFloortime/
overview/ index. shtml).
[43] (http:/ / helpguide. org/ mental/ parenting_bonding_reactive_attachment_disorder. htm), 'HelpGuide.org', 2011.
[44] Van Ijzendoorn MH, Bakermans-Kranenburg MJ (2006). "DRD4 7-repeat polymorphism moderates the association between maternal
unresolved loss or trauma and infant disorganization". Attach Hum Dev 8 (4): 291307. doi:10.1080/14616730601048159. PMID17178609.
[45] Zeanah CH (2007). "Reactive Attachment Disorder". In Narrow WE, First MB et al. (Eds.) Gender and age consideration in psychiatric
diagnosis. Washington, DC: American Psychiatric Association. ISBN 0890422958.
[46] Dozier M, Stovall KC, Albus KE, Bates B (2001). "Attachment for infants in foster care: the role of caregiver state of mind". Child Dev 72
(5): 146777. doi:10.1111/1467-8624.00360. PMID11699682.
[47] DSM-IV American Psychiatric Association 1994
[48] Mercer J, Sarner L and Rosa L (2003) Attachment Therapy on Trial: The Torture and Death of Candace Newmaker. Westport, CT: Praeger
ISBN 0275976750, pp. 98103.
[49] Mercer (2006), pp. 6470.
[50] Marshall,, P.J.; Fox, N.A. (2005). "Relationship between behavioral reactivity at 4 months and attachment classification at 14 months in a
[51] Prior and Glaser p.
[52] Mercer (2006) p.
[53] Fonagy P, Gergely G, Jurist EL, Target M (2006). Affect Regulation, Mentalization, and the Development of Self. Other Press (NY) ISBN
1892746344
[54] Chaffin et al., (2006) p 81
[55] Chaffin et al. (2006) p 82
[56] O'Connor TG, Zeanah CH (2003). "Attachment disorders: assessment strategies and treatment approaches" (http:/ / www. informaworld.
com/ openurl?genre=article& doi=10. 1080/ 14616730310001593974& magic=pubmed). Attach Hum Dev 5 (3): 22344.
doi:10.1080/14616730310001593974. PMID12944216. .
[57] Ziv Y (2005). "Attachment-Based Intervention programs: Implications for Attachment Theory and Research". In Berlin LJ, Ziv Y,
Amaya-Jackson L, Greenberg MT. Enhancing Early Attachments. Theory, Research, Intervention and Policy. Duke series in child
development and public policy. Guilford Press. pp.63. ISBN1-59385-470-6.
[58] Prior & Glaser (2006) p186-187
[59] Chaffin (2006) p 82
[60] Prior & Glaser (2006) p 262
[61] Chaffin et al. 2006, p. 7980. The APSAC Taskforce Report.
[62] Chaffin et al. (2006) p 79
[63] Boris 2003
[64] Mercer, Sarner & Rosa 2003
[65] Zeanah 2003
[66] Chaffin et al. (2006)
[67] "ATTACh White paper on coercion" (http:/ / www. attach. org/ WhitePaper. pdf) (PDF). ATTACh. 2007. . Retrieved 2008-03-16.
223
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wonder: testing the effectiveness of a new approach to mother-infant psychotherapy.' Infant Mental health
Journal 20, 429-451.
Cooper, G., Hoffman, K., Powell, B. and Marvin, R. (2007). The Circle of Security Intervention; differential
diagnosis and differential treatment. In Berlin, L.J., Ziv, Y., Amaya-Jackson, L. and Greenberg, M.T. (eds.)
Enhancing Early Attachments; Theory, research, intervention, and policy. The Guilford Press. Duke series in
Child Development and Public Policy. pp 127151. ISBN 1593854706.
Crittenden, P. M. (1992). Quality of attachment in the preschool years. Development and Psychopathology, 4,
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Dozier,M., Lindheim,O. and Ackerman, J., P. 'Attachment and Biobehavioral Catch-Up: An intervention targeting
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(eds) Enhancing Early Attachments; Theory, research, intervention, and policy The Guilford press. Duke series in
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Interdisciplinary Council on Developmental & Learning Disorders. (2007). Dir/floortime model. (http://www.
icdl.com/dirFloortime/overview/index.shtml)
Zeanah CH, Larrieu JA (1998). "Intensive intervention for maltreated infants and toddlers in foster care". Child
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Larrieu,J.A., & Zeanah,C.H. (2004). Treating infant-parent relationships in the context of maltreatment: An
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Levy KN, Meehan KB, Weber M, Reynoso J, Clarkin JF (2005). "Attachment and borderline personality
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file=PSP2005038002064). Psychopathology 38 (2): 6474. doi:10.1159/000084813. PMID15802944.
Lieberman, A.F., Silverman, R., Pawl, J.H. (2000). Infant-parent psychotherapy. In C.H. Zeanah, Jr. (ed.)
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Main, M. and Solomon, J. (1986). Discovery of an insecure disorganized/disoriented attachment pattern:
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Affective development in infancy, (pp.95124). Norwood, NJ: Ablex ISBN 0893913456
Main, M. and Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the
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years: Theory, research and intervention, (pp.121160). Chicago: University of Chicago Press. ISBN
0226306305.
Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment therapy on trial: The torture and death of Candace
Newmaker. Westport, CT: Praeger Publishers/Greenwood Publishing Group, Inc. ISBN 0275976750
Mercer, J (2006) Understanding Attachment: Parenting, child care and emotional development. Westport, CT:
Praeger ISBN 0275982173
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intervention with caregiver pre-school child dyads (http://www.circleofsecurity.org/docs/languages/08
AHD final.pdf). Attachment & Human Development Vol 4 No 1 April 2002 107124.
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/www.informaworld.com/openurl?genre=article&doi=10.1080/14616730310001593974&magic=pubmed).
Attach Hum Dev 5 (3): 22344. doi:10.1080/14616730310001593974. PMID12944216.
Prior, V., Glaser, D. Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice
(2006). Child and Adolescent Mental Health Series. Jessica Kingsley Publishers London ISBN 1843102455
OCLC 70663735
Schechter, D.S., Willheim, E. (2009). Disturbances of attachment and parental psychopathology in early
childhood. Infant and Early Childhood Mental Health Issue. Child and Adolescent Psychiatry Clinics of North
America, 18(3), 665-687.
Smyke, A. and Zeanah, C. (1999). Disturbances of Attachment Interview. Available on the Journal of the
American Academy of Child and Adolescent Psychiatry website at (http://www.jaacap.com/pt/re/jaacap/
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htm;jsessionid=H5QGQZ70p3VqMFJnGb5k207f5McynvWT1XQGv9hVxnDCPm4kp9Y1!901085598!181195628!8091!-1)
Toth S., Maughan A., Manly J., Spagnola M., Cicchetti D. (2002). "The relative efficacy of two in altering
maltreated preschool children's representational models: implications for attachment theory". Development and
psychopathology 14 (4): 877908. doi:10.1017/S095457940200411X. PMID12549708.
van den Boom, D. (1994). The influence of temperament and mothering on attachment and exploration: an
experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants. Child
Development 65, 14571477.doi:10.2307/1131277
van den Boom DC (1995). "Do first-year intervention effects endure? Follow-up during toddlerhood of a sample
of Dutch irritable infants". Child Dev 66 (6): 1798816. doi:10.2307/1131911. PMID8556900.
Van Ijzendoorn M, Bakermans-Kranenburg M. Attachment disorders and disorganized attachment: Similar and
different Attachment & Human Development, Volume 5, Number 3, September 2003 , pp.313320(8) DOI:
10.1080/14616730310001593938 (http://www.ingentaconnect.com/routledg/rahd/2003/00000005/
00000003/art00016)
Attachment disorder
Waters, E. and Deane, K (1985). Defining and assessing individual differences in attachment relationships:
Q-methodology and the organization of behavior in infancy and early childhood. In I. Bretherton and E. Waters
(Eds) Growing pains of attachment theory and research: Monographs of the Society for Research in Child
Development 50, Serial No. 209 (12), 4165 (http://www.eric.ed.gov/ERICWebPortal/custom/portlets/
recordDetails/detailmini.jsp?_nfpb=true&_&ERICExtSearch_SearchValue_0=EJ334806&
ERICExtSearch_SearchType_0=no&accno=EJ334806)
O'Connor TG, Zeanah CH (2003). "Attachment disorders: assessment strategies and treatment approaches" (http:/
/www.informaworld.com/openurl?genre=article&doi=10.1080/14616730310001593974&magic=pubmed).
Attach Hum Dev 5 (3): 22344. doi:10.1080/14616730310001593974. PMID12944216.
Zeanah CH, Keyes A, Settles L (2003). "Attachment relationship experiences and childhood psychopathology"
(http://www.annalsnyas.org/cgi/pmidlookup?view=long&pmid=14998869). Ann. N. Y. Acad. Sci. 1008:
2230. doi:10.1196/annals.1301.003. PMID14998869.
Zeanah, C., H. and Smyke, A., T. "Building Attachment Relationships Following Maltreatment and Severe
Deprivation" In Berlin,L.,J., Ziv, Y., Amaya-Jackson, L. and Greenberg, M., T. Enhancing Early Attachments;
Theory, research, intervention, and policy The Guilford Press, 2005 pps 195-216 ISBN 1593854706 (pbk)
Further reading
Holmes, J (2001). The Search for the Secure Base. Philadelphia: Brunner-Routledge. ISBN 1583911529
Cassidy, J; Shaver, P (eds.) (1999). Handbook of Attachment: Theory, Research, and Clinical Applications. New
York: Guilford Press. ISBN 1-57230-087-6.
Zeanah, CH (ed.) (1993). Handbook of Infant Mental Health. New York: Guilford Press. ISBN 1593851715
Bowlby, J (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. London:
Routledge; New York: Basic Books. ISBN 0-415-00640-6.
226
The term maternal deprivation is a catch-phrase summarising the
early work of psychiatrist and psychoanalyst, John Bowlby on the
effects of separating infants and young children from their mother (or
mother substitute)[1] although the effect of loss of the mother on the
developing child had been considered earlier by Freud and other
theorists. Bowlby's work on delinquent and affectionless children and
the effects of hospital and institutional care lead to his being
commissioned to write the World Health Organisation's report on the
Mother and child
mental health of homeless children in post-war Europe whilst he was
head of the Department for Children and Parents at the Tavistock
Clinic in London after World War II.[2] The result was the monograph Maternal Care and Mental Health published
in 1951, which sets out the maternal deprivation hypothesis.[3]
Bowlby drew together such empirical evidence as existed at the time from across Europe and the USA, including
Spitz (1946) and Goldfarb (1943, 1945). His main conclusions, that "the infant and young child should experience a
warm, intimate, and continuous relationship with his mother (or permanent mother substitute) in which both find
satisfaction and enjoyment" and that not to do so might have significant and irreversible mental health consequences,
were both controversial and influential.[4] The monograph was published in 14 different languages and sold over
400,000 copies in the English version alone. Bowlby's work went beyond the suggestions of Otto Rank and Ian
Suttie that mothering care was essential for development, and focused on the potential outcomes for children
deprived of such care.
The 1951 WHO publication was highly influential in causing widespread changes in the practices and prevalence of
institutional care for infants and children, and in changing practices relating to the stays of small children in hospitals
so that parents were allowed more frequent and longer visits. Although the monograph was primarily concerned with
the removal of children from their homes it was also used for political purposes to discourage women from working
and leaving their children in daycare by governments concerned about maximising employment for returned and
returning servicemen. The publication was also highly controversial with, amongst others, psychoanalysts,
psychologists and learning theorists, and sparked significant debate and research on the issue of children's early
relationships.
The limited empirical data and lack of comprehensive theory to account for the conclusions in Maternal Care and
Mental Health led to the subsequent formulation of attachment theory by Bowlby.[5] Following the publication of
Maternal Care and Mental Health Bowlby sought new understanding from such fields as evolutionary biology,
ethology, developmental psychology, cognitive science and control systems theory and drew upon them to formulate
the innovative proposition that the mechanisms underlying an infant's ties emerged as a result of evolutionary
pressure.[6] Bowlby claimed to have made good the "deficiencies of the data and the lack of theory to link alleged
cause and effect" in Maternal Care and Mental Health in his later work Attachment and Loss published between
1969 and 1980.[7]
Although the central tenet of maternal deprivation theorythat children's experiences of interpersonal relationships
are crucial to their psychological development and that the formation of an ongoing relationship with the child is as
important a part of parenting as the provision of experiences, discipline and child carehas become generally
accepted, "maternal deprivation" as a discrete syndrome is not a concept that is much in current use other than in
relation to severe deprivation as in "failure to thrive". In the area of early relationships it has largely been superseded
by attachment theory and other theories relating to even earlier infantparent interactions. As a concept, parental
deficiencies are seen as a vulnerability factor for, rather than a direct cause of, later difficulties. In relation to
227
institutional care there has been a great deal of subsequent research on the individual elements of privation,
deprivation, understimulation and deficiencies that may arise from institutional care.
History
Bri. Many traditions have stressed the grief of mothers over deprivation of their children but little has been said
historically about young children's loss of their mothers; this may have been because loss of the mother in infancy
frequently meant death for a breast-fed infant. In the 19th century, French society bureaucratised a system in which
infants were breast-fed at the homes of foster mothers, returning to the biological family after weaning, and no
concern was evinced at the possible effect of this double separation on the child.[8]
Sigmund Freud may have been among the first to stress the potential impact of loss of the mother on the developing
child, but his concern was less with the actual experience of maternal care than with the anxiety the child might feel
about the loss of the nourishing breast.[9] As little of Freud's theory was based on actual observations of infants, little
effort was made to consider the effects of real experiences of loss.
Following Freud's early speculations about infant experience with the
mother, Otto Rank suggested a powerful role in personality
development for birth trauma. Rank stressed the traumatic experience
of birth as a separation from the mother, rather than birth as an
uncomfortable physical event. Not long after Rank's introduction of
this idea, Ian Suttie, a British physician whose early death limited his
influence, suggested that the child's basic need is for mother-love, and
his greatest anxiety is that such love will be lost.[9] [10]
In the 1930s, David Levy noted a phenomenon he called "primary
affect hunger" in children removed very early from their mothers and
brought up in institutions and multiple foster homes. These children,
though often pleasant on the surface, seemed indifferent underneath.
He questioned whether there could be a "deficiency disease of the
emotional life, comparable to a deficiency of vital nutritional elements
Sister Irene at her New York Foundling Hospital
within the developing organism".[11] A few psychiatrists, psychologists
in the 1890s
and paediatricians were also concerned by the high mortality rate in
hospitals and institutions obsessed with sterility to the detriment of any
human or nurturing contact with babies. One rare paediatrician went so far as to replace a sign saying "Wash your
hands twice before entering this ward" with one saying "Do not enter this nursery without picking up a baby".[12]
In a series of studies published in the 1930s, psychologist Bill Goldfarb noted not only deficits in the ability to form
relationships, but also in the IQ of institutionalised children as compared to a matched group in foster care.[12] In
another study conducted in the 1930s, Harold Skeels, noting the decline in IQ in young orphanage children, removed
toddlers from a sterile orphanage and gave them to "feeble-minded" institutionalised older girls to care for. The
toddlers' IQ rose dramatically. Skeels study was attacked for lack of scientific rigour though he achieved belated
recognition decades later.[13]
Rene Spitz, a psychoanalyst, undertook research in the 1930s and '40s on the effects of maternal deprivation and
hospitalism. His investigation focused on infants who had experienced abrupt, long-term separation from the familiar
caregiver, as, for instance, when the mother was sent to prison. These studies and conclusions were thus different
from the investigations of institutional rearing. Spitz adopted the term anaclitic depression to describe the child's
reaction of grief, anger, and apathy to partial emotional deprivation (the loss of a loved object) and proposed that
when the love object is returned to the child within three to five months, recovery is prompt but after five months,
they will show the symptoms of increasingly serious deterioration. He called this reaction to total deprivation
228
"hospitalism". He was also one of the first to undertake direct observation of infants.[14]
hotly disputed and there was no widespread acceptance.[16]
229
[15]
The conclusions were
During the years of World War II, evacuated and orphaned children were the subjects of studies that outlined their
reactions to separation, including the ability to cope by forming relationships with other children. Some of this
material remained unpublished until the post-war period and only gradually contributed to understanding of young
children's reactions to loss.[17] [18]
Bowlby, who, unlike most psychoanalysts, had direct experience of working with deprived children through his
work at the London Child Guidance Clinic, called for more investigation of children's early lives in a paper
published in 1940. He proposed that two environmental factors were paramount in early childhood. The first was
death of the mother, or prolonged separation from her. The second was the mother's emotional attitude towards her
child.[19] This was followed by a study on fortyfour juvenile thieves collected through the Clinic. There were many
problematic parental behaviours in the samples but Bowlby was looking at one environmental factor that was easy to
document, namely prolonged early separations of child and mother. Of the forty-four thieves, fourteen fell into the
category which Bowlby characterised as being of an "affectionless character". Of these fourteen, twelve had suffered
prolonged maternal separations as opposed to only two of the control group.[20]
Maternal Care and Mental Health

Bowlby's work on delinquent and affectionless children and the effects of hospital and institutional care lead to his
being commissioned to write the World Health Organisation's report on the mental health of homeless children in
post-war Europe whilst he was head of the Department for Children and Parents at the Tavistock Clinic in London
after World War II.[2] Bowlby travelled on the Continent and in America, communicating with social workers,
paediatricians and child psychiatrists including those who had already published literature on the issue. These
authors were mainly unaware of each others' work and Bowlby was able to draw together the findings and highlight
the similarities described despite the variety of methods used ranging from direct observation to retrospective
analysis to comparison groups. In addition, there was work from England undertaken by Dorothy Burlingham and
Anna Freud on children separated from their families due to wartime disruption, and Bowlby's own work.[21] The
result was the monograph Maternal Care and Mental Health published in 1951, which sets out the maternal
deprivation hypothesis.[3] The WHO report was followed by the publication of an abridged version for public
consumption called Child Care and the Growth of Love. This book sold over half a million copies worldwide.
Bowlby tackled not only institutional and hospital care, but also policies of removing children from "unwed
mothers" and untidy and physically neglected homes, and lack of support for families in difficulties. In a range of
areas Bowlby cited the lack of adequate research and suggested the direction this could take.[22]
Principal concepts of Bowlby's theory

The quality of parental care was considered by Bowlby to be of vital importance to the child's development and
future mental health. It was believed to be essential that the infant and young child should experience a warm,
intimate, and continuous relationship with his mother (or permanent mother substitute) in which both found
satisfaction and enjoyment. Given this relationship, emotions of guilt and anxiety (characteristics of mental illness
when in excess) would develop in an organised and moderate way. Naturally extreme emotions would be moderated
and become amenable to the control of the child's developing personality. He stated, "It is this complex rich and
rewarding relationship with the mother in the early years, varied in countless ways by relations with the father and
with siblings, that child psychiatrists and many others now believe to underlie the development of character and
mental health."[4]
The state of affairs in which the child did not

have this relationship he termed "maternal
deprivation". This term covered a range from
almost complete deprivation, not uncommon in
institutions, residential nurseries and hospitals,
to partial deprivation where the mother, or
mother substitute, was unable to give the loving
care a small child needs, to mild deprivation
where the child was removed from the mother's
care but was looked after by someone familiar
whom he trusted.[23] Complete or almost
complete deprivation could "entirely cripple the
Residential nursery
capacity to make relationships". Partial
deprivation could result in acute anxiety, depression, neediness and powerful emotions which the child could not
regulate. The end product of such psychic disturbance could be neurosis and instability of character.[23] However, the
main focus of the monograph was on the more extreme forms of deprivation. The focus was the child's developing
relationships with his mother and father and disturbed parentchild relationships in the context of almost complete
deprivation rather than the earlier concept of the "broken home" as such.[3]
In terms of social policy, Bowlby advised that parents should be supported by society as parents are dependent on a
greater society for economic provision and "if a community values its children it must cherish its parents". Also
"husbandless" mothers of children under 3 should be supported to care for the child at home rather than the child be
left in inadequate care whilst the mother sought work. (It was assumed the mother of the illegitimate child would
usually be left with the child). Fathers left with infants or small children on their hands without the mother should be
provided with "housekeepers" so that the children could remain at home.[24] Other proposals included the proper
payment of foster homes and careful selection of foster carers,[25] and frank, informative discussions with children
about their parents and why they ended up in care and how they felt about it rather than the "least said, soonest
mended" approach. The point that children were loyal to and loved even the worst of parents, and needed to have
that fact understood non-judgementally, was strongly made.[26]
On the issue of removal of children from their homes, Bowlby emphasised the strength of the tie that children feel
towards their parents and discussed the reason why, as he put it, "children thrive better in bad homes than in good
institutions". He was strongly in favour of support being provided to parents and extended families to improve the
situation and provide care within the family rather than removal if possible.[27]
"Maternal"
Bowlby used the phrase "mother (or permanent mother substitute)".[4] As it is commonly used, the term maternal
deprivation is ambiguous as it is unclear whether the deprivation is that of the biological mother, of an adoptive or
foster mother, a consistent caregiving adult of any gender or relationship to the child, of an emotional relationship, or
of the experience of the type of care called "mothering" in many cultures. Questions about the exact meaning of this
term are by no means new, as the following statement by Mary Ainsworth in 1962 indicates: "Although in the early
months of life it is the mother who almost invariably interacts most with the child ... the role of other figures,
especially the father, is acknowledged to be significant ... [P]aternal deprivation ... has received scant attention ... [In
the case of] institutionalization ... the term 'parental deprivation' would have been more accurate, for the child has
been ... deprived of interaction with a father-figure as well as a mother-figure ... [It may be better to] discourage the
use of [the term 'deprivation'] and encourage the substitution of the terms 'insufficiency', 'discontinuity', and
'distortion' instead."[28] Ainsworth implies, neither the word "maternal" nor the word "deprivation" seems to be a
literally correct definition of the phenomenon under consideration.
230
A contemporary of Ainsworth spoke of "the mother, a term by which we mean both the child's actual mother and/or
any other person of either sex who may take the place of the child's physical mother during a significant period of
time".[29] However, another contemporary referred to "the quasi-mystical union of mother and child, of the dynamic
union that mother and child represent".[30]
Influence on institutionalised care

The practical effects of the publication of Maternal Care and Mental Health were described in the preface to the
WHO 1962 publication Deprivation of Maternal Care: A Reassessment of its Effects as "almost wholly beneficial"
with reference to widespread changes in the institutional care of children.[31]
The practice of allowing parents frequent visiting to hospitalised
children became the norm and there was a move towards placing
homeless children with foster carers, rather than in institutions, and a
move towards the professionalisation of alternative carers. In hospitals,
the change was given added impetus by the work of social worker and
psychoanalyst James Robertson who filmed the distressing effects of
separation on children in hospital and collaborated with Bowlby in
making the 1952 documentary film A Two-Year Old Goes to the
Hospital.[32]
Maternity ward, 1955
According to Michael Rutter, the importance of Bowlby's initial
writings on "maternal deprivation" lay in his emphasis that children's
experiences of interpersonal relationships were crucial to their psychological development and that the formation of
an ongoing relationship with the child was as important a part of parenting as the provision of experiences, discipline
and child care. Although this view was rejected by many at the time, the argument focussed attention on the need to
consider parenting in terms of consistency of caregivers over time and parental sensitivity to children's individuality
and it is now generally accepted.[33] Bowlby's theory sparked considerable interest and controversy in the nature of
early relationships and gave a strong impetus to what Mary Ainsworth described as a "great body of research" in
what was perceived as an extremely difficult and complex area.[31]
Psychoanalysis
Bowlby departed from psychoanalytical theory which saw the gratification of sensory needs as the basis for the
relationship between infant and mother.[2] Food was seen as the primary drive and the relationship, or "dependency"
was secondary.[5] He had already found himself in conflict with dominant Kleinian theories that children's emotional
problems are almost entirely due to fantasies generated from internal conflict between aggressive and libidinal
drives, rather than to events in the external world. (His breach with the psychoanalysts only became total and
irreparable after his later development of attachment theory incorporating ethological and evolutionary principles,
when he was effectively ostracised). Bowlby also broke with social learning theory's view of dependency and
reinforcement. Bowlby proposed instead that to thrive emotionally, children needed a close and continuous
caregiving relationship.[2]
Bowlby later stated that he had concluded that, contrary to the focus of psychoanalysts on the internal fantasy world
of the child, the important area to study was how a child was actually treated by his parents in real life and in
particular the interaction between them. He chose the actual removal of children from the home at this particular
time because it was a specific event, the effects of which could be studied, and because he believed it could have
serious effects on a child's development and because it was preventable. In addition, views that he had already
expressed about the importance of a child's real life experiences and relationship with carers had been met by "sheer
incredulity" by colleagues before World War II. This led him to see that far more systematic knowledge was required
231
of the effects on a child of early experiences. Bowlby and his colleagues were pioneers of the view that studies
involving direct observation of infants and children were not merely of interest but were essential to the
advancement of science in this area.[34]
Controversy, misinterpretation and criticism

Aside from his profound differences with psychoanalytic ideas, the theoretical basis of Bowlby's monograph was
controversial in a number of ways. Some profoundly disagreed with the necessity for maternal (or equivalent) love in
order to function normally,[35] or that the formation of an ongoing relationship with a child was an important part of
parenting.[33] The idea that early experiences have serious consequences for intellectual and psychosocial
development was controversial in itself.[36] Others questioned the extent to which his hypothesis was supported by
the evidence. There was criticism of the confusion of the effects of privation (no primary attachment figure) and
deprivation (loss of the primary attachment figure) and in particular, of the failure to distinguish between the effects
of the lack of a primary attachment figure and the other forms of deprivation and understimulation that might affect
children in institutions.[37]
It was also pointed out that there was no explanation of how experiences subsumed under the broad heading of
"maternal deprivation" could have effects on personality development of the kinds claimed. Bowlby explained in his
1988 work that the data were not at the time "accommodated by any theory then current and in the brief time of my
employment by the World Health Organisation there was no possibility of developing a new one". He then goes on
to describe the subsequent development of attachment theory.[5]
In addition to criticism, his ideas were often oversimplified, misrepresented, distorted or exaggerated for various
purposes. This heightened the controversy.[36] In 1962, the WHO published Deprivation of Maternal Care: A
Reassessment of its Effects to which Mary Ainsworth, Bowlby's close colleague, contributed with his approval, to
present the recent research and developments and to address misapprehensions.[31]
Bowlby's work was misinterpreted to mean that any separation from the natural mother, any experience of
institutional care or a multiplicity of "mothers" necessarily resulted in severe emotional deprivation and sometimes,
that all children undergoing such experiences would develop into "affectionless children". As a consequence it was
claimed that only 24-hour care by the same person (the mother) was good enough, day care and nurseries were not
good enough and mothers should not go out to work. The WHO advised that day nurseries and creches could have a
serious and permanent deleterious effect.[37] Such strictures suited the policies of governments concerned about
finding employment for returned and returning servicemen after World War II.[38] In fact, although Bowlby was of
the view that proper care could not be provided "by roster", he was also of the view that babies should be
accustomed to regular periods of care by another and that the key to alternative care for working mothers was that it
should be regular and continuous.[37] He addressed this point in a 1958 publication called Can I Leave My Baby?.
Ainsworth in the WHO 1962 publication also attempted to address this misapprehension by pointing out that the
requirement for continuity of care did not imply an exclusive motherchild pair relationship.[28]
Bowlby's quotable remark, that children thrived better in bad homes than in good institutions,[39] was often taken to
extremes leading to reluctance on the part of Children's Officers (the equivalent of child care social workers) to
remove children from homes however neglectful and inadequate. In fact, although Bowlby mentioned briefly the
issue of "partial deprivation" within the family, this was not fully investigated in his monograph as the main focus
was on the risks of complete or almost complete deprivation.[40]
Michael Rutter made a significant contribution to the controversial issue of Bowlby's maternal deprivation
hypothesis. His 1981 monograph and other papers (Rutter 1972; Rutter 1979) comprise the definitive empirical
evaluation and update of Bowlby's early work on maternal deprivation. He amassed further evidence, addressed the
many different underlying social and psychological mechanisms and showed that Bowlby was only partially right
and often for the wrong reasons. Rutter highlighted the other forms of deprivation found in institutional care and the
complexity of separation distress; and suggested that anti-social behaviour was not linked to maternal deprivation as
232
233
such but to family discord. The importance of these refinements of the maternal deprivation hypothesis was to
reposition it as a "vulnerability factor" rather than a causative agent, with a number of varied influences determining
which path a child would take.[41]
Rutter has more recently advised attention to the complexity of development and the roles of genetic as well as
experiential factors, noting that separation is only one of many risk factors related to poor cognitive and emotional
development.[42]
Fathers
In accordance with the prevailing social realities of his time, namely
the assumption that the daily care of infants and small children was
undertaken by women and in particular, mothers, Bowlby referred
primarily to mothers and "maternal" deprivation, although the words
"parents" and "parental" are also used.[2] Fathers are mentioned only in
the context of the practical and emotional support they provide for the
mother but the monograph contains no specific exploration of the
father's role. Nor is there any discussion as to whether the maternal role
had, of necessity, to be filled by women as such. Bowlby's work was
misinterpreted by some to mean natural mothers only.[43]
The 1962 WHO publication contains a chapter on the effect of
"paternal deprivation", there having by 1962 been some limited
research on the issue which illustrated the importance of the father's
relationship with his children.[43] The hope was expressed by Ainsworth that in the future there would be more such
research and indeed her early research, which contributed significantly to attachment theory, covered infants
relationships with all family members. It was also stated that in relation to institutional care, "parental deprivation"
would have been more accurate, although Ainsworth preferred the terms "insufficiency", "discontinuity" and
"distortion" to either.[28]
Father and child
Michael Rutter in Maternal Deprivation Reassessed (1972), described by New Society as a "classic in the field of
child care", argued that research showed that it did not matter which parent the child got on well with as long as he
got on well with one of them, that both parents influence their child's development and that which parent is more
important varies with age, sex and temperamental development. He concluded, "For some aspects of development
the same-sexed parent seems to have a special role, for some the person who plays and talks most with the child and
for others the person who feeds the child. The father, the mother, brother and sisters, friends, school-teachers and
others all have an impact on development, but their influences and importance differ for different aspects of
development. A less exclusive focus on the mother is required. Children also have fathers!"[40]
Within attachment theory, Bowlby, in Attachment and Loss, volume one of Attachment (1969), makes it quite clear
that infants become attached to carers who are sensitive and responsive in their social interactions with them and
that this does not have to be the mother or indeed a female. As a matter of social reality mothers are more often the
primary carers of children and therefore are more likely to be the primary attachment figure, but the process of
attachment applies to any carer and infants develop a number of attachments according to who relates to them and
the intensity of the engagement.[44] However, attachment theory relates to the development of attachment behaviours
and relationships after about 7 months of age and there are other theories and research relating to earlier carerinfant
interactions.
Schaffer in Social Development (1996) suggests that the fatherchild relationship is primarily a cultural construction
shaped by the requirements of each society. In societies where the care of infants has been assigned to boys rather
than girls, no difference in nurturing capacity was found.[45] [46]
Feminist criticism
There were three broad criticisms aimed at the idea of maternal deprivation from feminist critics.[47] The first was
that Bowlby overstated his case. The studies on which he based his conclusions involved almost complete lack of
maternal care and it was unwarranted to generalise from this view that any separation in the first three years of life
would be damaging. Subsequent research showed good quality care for part of the day to be harmless. The idea of
exclusive care or exclusive attachment to a preferred figure, rather than a hierarchy (subsequently thought to be the
case within developments of attachment theory) had not been borne out by research and this view placed too high an
emotional burden on the mother. Secondly, they criticised Bowlby's historical perspective and saw his views as part
of the idealisation of motherhood and family life after World War II. Certainly his hypothesis was used by
governments to close down much needed residential nurseries although governments did not seem so keen to pay
mothers to care for their children at home as advocated by Bowlby. Thirdly, feminists objected to the idea of
anatomy as destiny and concepts of "naturalness" derived from ethnocentric observations. They argued that
anthropology showed that it is normal for childcare to be shared by a stable group of adults of which maternal care is
an important but not exclusive part.[47]
Maternal deprivation today

Whilst Bowlby's early writings on maternal deprivation may be seen as part of the background to the later
development of attachment theory, there are many significant differences between the two. At the time of the 1951
publication, there was little research in this area and no comprehensive theory on the development of early
relationships.[5] Aside from its central proposition of the importance of an early, continuous and sensitive
relationship, the monograph concentrates mostly on social policy. For his subsequent development of attachment
theory, Bowlby drew on concepts from ethology, cybernetics, information processing, developmental psychology
and psychoanalysis. The first early formal statements of attachment theory were presented in three papers in 1958,
1959 and 1960. His major work Attachment was published in three volumes between 1969 and 1980. Attachment
theory revolutionised thinking on the nature of early attachments and extensive research continues to be
undertaken.[6]
According to Zeanah, "ethological attachment theory, as outlined by John Bowlby ... 1969 to 1980 ... has provided
one of the most important frameworks for understanding crucial risk and protective factors in social and emotional
development in the first 3 years of life. Bowlby's (1951) monograph, Maternal Care and Mental Health, reviewed the
world literature on maternal deprivation and suggested that emotionally available caregiving was crucial for infant
development and mental health."[48] Beyond that broad statement, which is now generally accepted, little remains of
the underlying detail of Bowlby's theory of maternal deprivation that has not been either discredited or superseded by
attachment theory and other child development theories and research, except in the area of extreme deprivation.
The opening of East European orphanages in the early 1990s following the end of the Cold War provided substantial
opportunities for research on attachment and other aspects of institutional rearing, however such research rarely
mentions "maternal deprivation" other than in a historical context. Maternal deprivation as a discrete syndrome is a
concept that is rarely used other than in connection with extreme deprivation and failure to thrive. Rather there is
consideration of a range of different lacks and deficiencies in different forms of care, or lack of care, of which
attachment is only one aspect, as well as consideration of constitutional and genetic factors in determining
developmental outcome.[42] Subsequent studies have however confirmed Bowlby's concept of "cycles of
disadvantage" although not all children from unhappy homes reproduce the deficiencies in their own experience.[49]
Rather, it is now conceptualised as a series of pathways through childhood and a number of varied influences will
determine which path a particular child takes.[37]
234
The maternal deprivation concept outside mainstream psychology

The idea that separation from the female caregiver has profound effects is one with considerable resonance outside
the conventional study of child development. In United States law, the "tender years" doctrine was long applied
when custody of infants and toddlers was preferentially given to mothers. Over the last decade or so, some decisions
appear to have been derived from the "tender years" concept, but others involve the contrary assumption that a
2-year-old is too young to have developed a relationship with either parent.[50]
Concern with the negative impact of separation from the mother is characteristic of the belief systems behind some
complementary and alternative (CAM) psychotherapies. Such belief systems are concerned not only with the impact
of the young child's separation from the care of the mother, but with an emotional attachment between mother and
child which advocates of these systems believe to develop prenatally. Such attachment is said to lead to emotional
trauma if the child is separated from the birth mother and adopted, even if this occurs on the day of birth and even if
the adoptive family provides all possible love and care. These beliefs were at one time in existence among some
legitimate psychologists of psychoanalytic background.[9] [51] Today, however, beliefs in prenatal communication
between mothers and infants are largely confined to unconventional thinkers such as William Emerson.[52]
Belief in prenatal fetal awareness, mental communication between mother and unborn child, and emotional
attachment of child to mother as a prenatal phenomenon, are concepts that connect easily to the unfounded
assumption that all adopted children suffer emotional disorders. These beliefs are also congruent with CAM
psychotherapies such as attachment therapy (not based on attachment theory), which purport to bring about age
regression and to recapitulate early development to produce a better outcome.[53]
Notes
[1] Holmes J. p. 221
[2] Bretherton, I. (1992). "The Origins of Attachment Theory: John Bowlby and Mary Ainsworth". Developmental Psychology 28 (5): 759775.
doi:10.1037/0012-1649.28.5.759.
[3] Bowlby, J. (1951). Maternal Care and Mental Health. Geneva: World Health Organisation. ISBN1568217579.
[4] Bowlby J. (1951) p. 11
[5] Bowlby J. (1988) p. 24
[6] Cassidy, J. (1999). "The Nature of the Child's Ties". In Cassidy, J. and Shaver, P.R.. Handbook of Attachment: Theory, Research and Clinical
Applications. Guilford press. ISBN978-1572308268.
[7] Bowlby, J. (1986). "Maternal Care and Mental Health" (http:/ / www. garfield. library. upenn. edu/ classics1986/ A1986F063100001. pdf)
(PDF). .
[8] Fildes, V. (1988). Wet Nursing. New York: Blackwell. ISBN978-0631158318.
[9] Brown, JAC (1961). Freud and the post-Freudians. London: Penguin.
[10] Suttie, I. (1935). The Origins of Love and Hate. London: Penguin. ISBN0415210429.
[11] Karen R. pp. 1317
[12] Karen R. pp. 2021
[13] Karen R. pp. 1822
[14] Spitz, R. (1945). "Hospitalism: An inquiry into the genesis of psychiatric conditions in early childhood". Psychoanalytic Study of the Child
1: 5374. PMID21004303.
[15] Spitz R (1950). "Relevance of direct infant observation". Psychoanalytic Study of the Child 5: 6673.
[16] Karen R. p. 25
[17] Freud, A. and Burlingham, D.T. (1943). War and Children. New York: Medical War Books. ISBN0837169429.
[18] Freud, A. and Burlingham, D.T. (19391945). Infants Without Families and Reports on the Hampstead Nurseries. The Writings of Anna
Freud. 3. New York: International Universities Press.
[19] Karen J. pp. 2629
[20] Bowlby J (1944). "Forty-four juvenile thieves: Their characters and home life". International Journal of Psychoanalysis 25 (1952):
10727. "sometimes referred to by Bowlby's colleagues as "Ali Bowlby and the Forty Thieves""
[21] Karen R. pp. 5962
[22] Karen R. pp. 6266
[23] Bowlby J. (1951) pp. 1112
[24] Bowlby J. (1951) pp. 8490
[25] Bowlby J. (1951) pp. 117122
235
[26] Bowlby J. (1951) pp. 124126
[27] Bowlby J. (1951) pp. 6792
[28] Ainsworth, M.D. (1962). "The Effects of Maternal Deprivation: A Review of Findings and Controversy in the Context of Research
Strategy". Deprivation of Maternal Care: A Reassessment of its Effects. Public Health Papers, No. 14. Geneva: World Health Organization.
[29] Spitz, R.A. (1949). "Autoerotism". Psychoanalytic Study of the Child 3: 85120.
[30] Rank, B. (1949). "Aggression". Psychoanalytic Study of the Child 3: 4348.
[31] Ainsworth, M.; et al. (1962). Deprivation of Maternal Care: A Reassessment of its Effects. Geneva: World Health Organization, Public
Health Papers, No. 14.
[32] Schwartz, J. (1999). Cassandra's Daughter: A History of Psychoanalysis. Viking/Allen Lane. p.225. ISBN0670886238.
[33] Rutter, M. (May 1995). "Clinical implications of attachment concepts: retrospect and prospect". J Child Psychol Psychiatry 36 (4): 54971.
doi:10.1111/j.1469-7610.1995.tb02314.x. PMID7650083.
[34] Bowlby J. (1988) pp. 4345
[35] Wootton B. (1962). "A Social Scientist's Approach to Maternal Deprivation". Deprivation of Maternal Care: A Reassessment of its Effects.
Public Health Papers, No. 14. Geneva: World Health Organization. pp. 255266.
[36] Karen R. p. 65
[37] Rutter M. (1981). Maternal Deprivation Reassessed: 2nd edition. Harmondsworth: Penguin. ISBN978-0140227000.
[38] Holmes J. pp. 4546
[39] Bowlby J. (1951) p. 68
[40] Rutter M. (1972). Maternal Deprivation Reassessed. Harmondsworth: Penguin. ISBN0140805613.
[41] Holmes J. pp. 4951
[42] Rutter M. (2002). "Nature, nurture, and development: from evangelism through science toward policy and practice" (http:/ / www.
blackwell-synergy. com/ openurl?genre=article& sid=nlm:pubmed& issn=0009-3920& date=2002& volume=73& issue=1& spage=1). Child
Dev 73 (1): 121. doi:10.1111/1467-8624.00388. PMID14717240. .
[43] Andry R.G. (1962). "Paternal and Maternal Roles and Delinquency". Deprivation of Maternal Care: A Reassessment of its Effects. Public
Health Papers, No. 14. Geneva: World Health Organization.
[44] Bowlby J. (1969, 1982). Attachment: Attachment and Loss. Vol 1. London: Pimlico. ISBN978-0712674713.
[45] Schaffer, H.R. (1996). Social Development: an introduction. Oxford: Blackwell. ISBN978-0631185741.
[46] Field, T. (1978). "Interaction behaviours of primary versus secondary caretaker fathers". Developmental Psychology 14 (2): 183184.
doi:10.1037/0012-1649.14.2.183.
[47] Holmes J. pp. 4548
[48] Zeanah, C.H. (February 1996). "Beyond insecurity: a reconceptualization of attachment disorders of infancy" (http:/ / content. apa. org/
journals/ ccp/ 64/ 1/ 42). J Consult Clin Psychol 64 (1): 4252. doi:10.1037/0022-006X.64.1.42. PMID8907083. .
[49] Holmes J. p. 51
[50] Mercer, J. (2006). Understanding Attachment: Parenting, Child Care, and Emotional Development. Westport, CT: Praeger.
ISBN978-0275982171.
[51] Freud, W.E. (1973). "Prenatal attachment and bonding". In Greenspan, S.I. and Pollock, G.H.. The Course of Life, Vol. I, Infancy. Nadison,
CT: International Universities Press.
[52] Emerson, W.R. (1996). "The vulnerable pre-nate". Pre- and Perinatal Psychology Journal 10 (3): 125142.
[53] Mercer, J.; Sarner, L.; Rosa, L. (2003). Attachment therapy On Trial: The Torture and Death of Candace Newmaker. Child Psychology &
Mental Health. Westport, CT: Praeger. ISBN978-0275976750.
References
Bowlby, J. (1951). Maternal Care and Mental Health. Geneva: World Health Organisation. ISBN1568217579.
Bowlby, J. (1988). A Secure Base: Clinical Applications of Attachment Theory. London: Routledge.
ISBN0415006406.
Holmes, J. (1993). John Bowlby & Attachment Theory. London: Routledge. ISBN978-0415077309.
Karen, R. (1998). Becoming Attached: First Relationships and How They Shape Our Capacity to Love. Oxford,
New York: Oxford University Press. ISBN0-19-511501-5.
Rutter, M. (1981). Maternal Deprivation Reassessed: 2nd edition. Harmondsworth: Penguin.
ISBN978-0140227000.
236
External links
Rene Spitz's film "Psychogenic Disease in Infancy" (1957) (http://www.archive.org/details/PsychogenicD)

Nutrition and weight management before and during pregnancy has a
profound effect on the development of infants. This is a rather critical
time for healthy fetal development as infants rely heavily on maternal
stores and nutrient for optimal growth and health outcome later in
life.[1] Prenatal nutrition addresses nutrient recommendations before
and during pregnancy. Birth weight of the newborn at delivery reflects
the sufficiency and the quality of maternal nutrient for the fetus during
pregnancy. Prenatal nutrition has a strong influence on birth weight
and further development of the infant.
A common saying that 'a woman is eating for two while pregnant'
implies that a mother should consume twice as much during
pregnancy. However, in reality this is not true. Although maternal
consumption will directly affect both herself and the growing fetus,
over eating excessively will compromise the baby's health as the infant
will have to work extra hard to become healthy in the future.
Pregnancy.
Compared with the infant, the mother possesses the least biological
risk. Therefore, excessive calories, rather than going to the infant, often
get stored as fat in the mother.[2] On the other hand, insufficient consumption will result in lower birth weight.
Maintaining a healthy weight during gestation lowers adverse risks on infants such as birth defects, as well as
chronic conditions in adulthood such as obesity, diabetes, and cardiovascular disease (CVD).[1] Ideally, the rate of
weight gain should be monitored during pregnancy to support the most ideal infant development.[3]
Background
Barker's Hypothesis
The "Barker Hypothesis", or Thrifty phenotype, states that conditions during pregnancy will have long term effects
on adult health. Associated risk of lifelong diseases includes cardiovascular disease, type-2 diabetes, obesity, and
hypertension. Babies born lighter in weight appear to have an increased rate of mortality than babies born at a
heavier weight.[4] This does not mean that heavy babies are less of a concern. Death rate would rise as birth weight
increases beyond normal birth weight range.[5] Therefore, it is important to maintain a healthy gestational weight
gain throughout pregnancy for achieving the optimal infant birth weight.
When this theory was first proposed, it was not well accepted and was met with much skepticism.[6] The main
criticism was that confounding variables such as environmental factors could attribute to many of the chronic
diseases such that low birth weight alone should not be dictated as an independent risk factor.[5] Subsequent research
studies supporting the theory attempted to adjust these environmental factors and in turn, provided more convincing
results with minimal confounding variables.[5]
"Barker's Hypothesis" is also known as Fetal Programming Hypothesis. The word programming illustrates the
idea that during critical periods in early fetal development, there are persisting changes in the body structure and
function that are caused by environmental stimuli.[6] This relates to the concept of developmental plasticity where
237
238
our genes can express different ranges of physiological or morphological states in response to the environmental
conditions during fetal development.[5]
If the mother has an inadequate diet then it signals the baby that the living condition in the long term will be
impoverished.[5] Consequently the baby adapts by changing its body size and metabolism to prepare for harsh
conditions of food shortages after birth.[5] Physiological and metabolic processes in the body undergo long term
changes as a result of restricted growth.[5] When the living environment switches from the condition of malnutrition
to a society of abundant supply of nutrients, this exposes the baby to a bountiful environment that goes against what
its body is designed for and this places the baby at a higher risk of adult diseases later in adulthood.[5] By the same
token, if the fetus growing in the womb of a healthy mother is exposed to prolonged famine after birth, the infant
would be less adaptive to the harsh environment than low birth weight babies.[4]
The Dutch Famine

Since small birth weight is associated with an increased risk of chronic
diseases in later life, and poor maternal nutrition during gestation
contributes to restricted fetal development, maternal malnutrition may
be a cause of increased disease susceptibility in adulthood.
The Dutch famine of 1944 or the 'Hunger Winter' during World War
II serves as an epidemiological study that is used to examine the effects
of maternal under-nutrition during different gestational stages. The
famine was a period (roughly five to six months) of extreme food
shortage in the west of Netherlands.[7] The famine was imposed on a
previously well-nourished population and the official daily ration for
the general adult population gradually decreased from 1800 calories in
December 1943 to 1400 calories in October 1944 to below 1000
calories in the late November 1944.[8] December 1944 to April 1945
was the peak of the famine where the official daily ration fell abruptly
to about 400~800 calories.[8] Even though pregnant and lactating
women had extra food during the famine, these extra supplies could no
longer be provided at the height of the famine.[7] In the early May
The tile is a tribute to the Dutch Famine.
1945, the liberation of the Netherlands restored the food supply. The
daily ration had increased to more than 2000 calories in June 1945.[8]
What is unique about Dutch Famine as an experimental study on the effects of maternal malnutrition is that the
population was strictly circumscribed in time and place and the sudden onset and relief of the famine was imposed
on a previously well-nourished population.[7]
The Dutch Famine during World War II had a profound effect on the health condition of the general public,
especially women who conceived during the period of time. The period of maternal starvation is shown to have
limited intrauterine growth and has been identified as one of the most important contributor to coronary heart disease
as well as other chronic diseases later in life.[7] These findings agree well with Barkers hypothesis; it supports the
theory that maternal under-nutrition leads to a lower birth weight due to restricted intrauterine development and
ultimately leads to higher risks of chronic conditions in adult life.
239
Recommendations for Pregnant Women

Gestation Stages
Gestation is the period of embryo development from conception to
birth.[1] Gestation is about 40 weeks in humans and is divided into
three trimesters, each spanning 3 months.[1] Gestational stages, on the
other hand, are based on physiological fetal development, which
include blastogenesis, embryonic stage and fetal stage.[1]
Blastogenesis is the stage from fertilization to about 2 weeks. The
fertilized egg or the zygote becomes a blastocyst where the outer layer
and the inner cell mass differentiate to form placenta and the fetus
respectively. Implantation occurs at this stage where the blastocyst
becomes buried in the endometrium.[1]
Life size model of a 8-week-old fetus (at the end

of embryonic stage).
Embryonic stage is approximately from 2 weeks to 8 weeks. It is also

in this stage where the blastocyst develops into an embryo, where all major features of human are present and
operational by the end of this stage.[1]
Fetal stage is from 9 weeks to term. During this period of time, the embryo develops rapidly and becomes a fetus.
Pregnancy becomes visible at this stage.[1]
Embryo at 8 weeks after

[9]
fertilization
Fetus at 18 weeks after

[10]
fertilization
Fetus at 38 weeks after

[11]
fertilization
Pre-pregnancy Weight and Moochy Gestational Weight Gain

The pattern and amount of weight gain is closely associated with
gestational stages.[1] Additional energy is required during pregnancy
due to the expansion of maternal tissues and stores in order to support
fetal development.
In the first trimester (blastogenesis and early embryonic stages), the
mother experiences a minimal weight gain (approximately 0.5-2
kilograms), while the embryo weighs only 6grams, which is
approximately the weight 6 raisins.[1]
In the second trimester and third trimester (late embryonic and fetal
BMI chart.
stages), the fetus undergoes rapid weight growth and the weight
increases to about 3000~4000grams.[1] It is also in this period that the
mother experiences the bulk of her gestational weight gain but the amount of weight gain varies greatly. The amount
of weight gain depends strongly on their pre-pregnant weight.[3]
240
Generally, a normal weight is strongly recommended for mothers when entering gestation, as it promotes overall
health of infants.[3] Maternal body weight is determined by the Body Mass Index (BMI) which is defined as the
weight in kilograms divided by the square of the height in meters.[12] While pregnant, body weight should be
managed within the recommended gestational weight gain range as it is shown to have a positive effect on pregnancy
outcomes. Gestational weight gain should also be progressive and the recommended weight depends on pre-pregnant
body weight.[1]
Since the total weight gain depends on pre-pregnant body weight, it is recommended that underweight women
should undergo a larger weight gain for healthy pregnancy outcomes, and overweight or obese women should
undergo a smaller weight gain.[3]
Normal Weight Women
Women having a BMI of 18.5~24.9 are classified as having a normal
or healthy body weight. This group have the lowest risk of adverse
birth outcomes.[3] Their babies are least likely to either be low-birth
weight or high-birth weight. It is advised that women with a normal
weight before pregnancy should gain a total of 11.5 kilograms to 16.0
kilograms throughout gestation, which is approximately 0.4 kilogram
per week in the second and third trimesters.[3]
In order to maintain a steady weight gain, the mother should engage in
mild physical activities. Participating in aerobic activities such as
walking and swimming 3 to 4 times a week is usually adequate.[3]
Vigorous physical activity is not recommended since an excessive loss
of calories is induced which is not sufficient to support fetal development.
Health choices such as low-fat milk and

alternatives, fruits, and vegetables should be
emphasized for pregnant women.
A proper diet is also essential to healthy weight gain. The common saying a women is eating for two often leads to
mothers thinking that they should eat twice as much. In reality, only a small increase in caloric intake is needed to
provide for the fetus; approximately 350 calories more in the second trimester and 450 calories more in the third
trimester.[3] Also, healthy choices should be emphasized for these extra calories such as whole grain products, fruits
and vegetables as well as low-fat dairy alternatives.[3]
Underweight Women
Women's are classified as underweight if they have a pre-pregnant BMI of 18.5 or below.[3] Low pre-pregnancy BMI
increases the risk of low birth weight infants, but the risk can be balanced by an appropriate gestational weight gain
from 12.5 to 18.0 kilograms in total, or about 0.5 kilogram each week in the second and third trimesters.[3]
Underweight women usually have inadequate nutrient stores that are not enough to provide for both herself and the
fetus.[3] While exercise and a proper diet are both needed to maintain the recommended weight gain, a balance
between the two is very important. As such, underweight mothers should seek individualized advice tailored
especially for themselves.[3]
Overweight and Obese Women
Women with a high pre-pregnancy weight are classified as overweight or obese, defined as having a BMI of 25 or
above.[3] Women with BMI between 25 and 29.9 are in the overweight category and should gain between 7.0 and
11.5 kilograms in total, corresponding to approximately 0.28 kilogram each week during the second and third
trimesters.[3] Whereas women with BMI of 30 or above are in the obese category and should gain only between 5.0
and 9.0 kilograms overall, which equates to roughly 0.2 kilogram per week in the second and third trimesters.[3]
In general, walking is encouraged for mothers classified in this category.[3] Unfortunately, estimated energy
requirements for them are not available.[3] As such, they are encouraged to record activity and intake level. This can
241
be done with the help of tools such as My Food Guide Servings Tracker from Health Canada and EATracker that are
available online.[3] In extreme cases where the BMI exceeds 35, help from a registered dietitian is recommended.[3]
Summary Table
The following table summarizes the recommended rate of weight gain and total weight gain according to
pre-pregnancy BMI for singleton pregnancies. The first column categorizes the type of body weight based on the
Body Mass Index. The second column summarizes the total recommended weight gain for each type of body weight,
and the third column presents the corresponding weekly weight gain during the period when the fetus undergoes
rapid growth (during second and third trimesters). In extreme cases, the amount of total and weekly weight gain can
vary by a factor of two depending on a woman's pre-pregnant weight. For example, a woman in the obese category is
recommended to gain a total of 5~9 kilograms, whereas an underweight woman needs to gain up to 18 kilograms in
weight.
Pre-pregnancy BMI Category Recommendated Total Weight Gain Weekly Weight Gain (after 12 weeks)
Underweight BMI <18.5
12.5~18kg (28~40lb)
0.5kg (1.0lb)
Healthy weight BMI 18.5~ 24.9 11.5~16kg (25~35lb)
0.4kg (1.0lb)
Overweight BMI 25.0~ 29.9
7.0~ 11.5kg (15~25lb)
0.3kg (0.6lb)
Obese BMI > 30
5.0~9.0kg (11~20lb)
0.2kg (0.5lb)
.[13]
Recommendations for Low and High Birth Weight

Diagnosis
In order to have a good estimate of birth weight, ultrasonography or
ultrasound during pregnancy and the date of last menstrual period are
needed.[14] Measured values from ultrasonography are compared with
the growth chart to estimate fetal weight.[15]
Crown rump length can be used as the best ultrasonographic
measurement for correct diagnosis of gestational age during the first
trimester.[14] This correlation between crown rump length and
gestational age would be most effectively shown when no growth
defects are observed in first trimester.[14] If growth defects were
observed in the first trimester, then the measurement of the date of last
menstrual period becomes quite important since the crown heel length
has become less of a reliable indicator of gestational age.[14]
After the 20th week of pregnancy, the mother would need to visit the
doctor for the measurement of fundal height, which is the length from
Ultrasound of fetus (~3 inches in length).
the top portion of the uterus to the pubic bone.[15] The length measured
in centimeters should correspond to the number of weeks that the
[15]
mother has been pregnant.
If the measured number is higher or lower than 2 centimetres, further tests using
ultrasound would be needed to check the results.[15] Another way to estimate fetal size is to look at the mothers
weight gain.[15] How much weight the mother gains can be used to indicate fetal size.[15]
242
Low Birth Weight

There are two ways to determine small for gestational age infants.
Many research studies agree that SGA babies are those with birth
weight or crown heel length measured at two standard deviations or
more below the mean of the infants gestational age, based on data
consisting of a reference population.[14] Other studies classify SGA
babies as those with birth weight values below the 10th percentile of
the growth chart for babies of the same gestational age.[16] This
indicates that these babies are weighing less than 90% of babies of the
same gestational age.
Birth weight chart.
Many factors, including maternal, placental, and fetal factors, contribute to the cause of impaired fetal growth.[14]
There are a number of maternal factors, which include age, nutritional status, alcohol abuse, smoking, and medical
conditions.[14] Insufficient uteroplacental perfusion is an example of a placental factor.[14] Chromosomal
abnormalities and genetic diseases are examples of fetal factors.[14] Identification of the causes of SGA for
individual cases aids health professionals in finding ways to handle each unique case.[17] Nutritional counseling,
education, and consistent monitoring can be helpful to assist women bearing SGA infants.[17]
Complications for the infant include limitations in body growth since the number and size of cells in tissues is
smaller.[15] The infant likely did not receive enough oxygen during pregnancy so the oxygen level is low.[15] It is
also more difficult to maintain body temperature since there is less blood flow within the small body.[15]
As such, it is necessary to monitor oxygen level to make sure that it doesnt go too low. If the baby cant suck well,
then it may be necessary for tube-feed.[15] Since the baby cannot maintain body temperature sufficiently, a
temperature-controlled bed would help to keep their bodies from losing heat.[15] There are ways to help prevent SGA
babies. Monitoring fetal growth can help identify the problem during pregnancy well before birth.[15] It would be
beneficial to seek professional help and counseling.
High Birth Weight

Research show that when birth weights of infants are greater than the
90th percentile of the growth chart for babies of the same gestational
age, they are considered large for gestational age or LGA.[18] This
indicates that these babies are weighing more than 90% of babies of
the same gestational age.[18]
Many factors account for LGA babies, including genetics and
excessive nutrient supply.[18] It seems that a common factor for LGA
babies is whether or not the mother has diabetes when she is
pregnant.[18] An indicator for excessive growth, regardless of
Ultrasound examination.
gestational age, is the appearance of macrosomia.[19] Many
complications are observed for LGA babies and their mothers. A longer delivery time may be expected since it is a
difficult birth.[18] The infant would likely suffer hypoglycemia (low glucose level in the blood) after birth.[18] The
infant would also have difficulty breathing.[18]
There might be a need for early delivery if the baby gets too big and perhaps Caesarean section would be needed.[18]
Since the baby is bigger in size, theres a higher chance of injury when coming out of the mothers body.[18] To
increase the blood glucose level in blood, a glucose/water solution can be offered to the infant.[18]
There are ways to help prevent LGA babies. It is necessary to monitor fetal growth and perform pregnancy
examinations to determine health status and detect any possibility of unrecognized diabetes.[18] For diabetic mothers,

careful management of diabetes during pregnancy period would be helpful in terms of lowering some of the risks of
LGA.[18]
Points to Consider
The goal of pregnancy is to have a healthy baby. Maintaining healthy and steady weight gain during pregnancy
promotes overall health and reduces the incidence of prenatal morbidity and mortality. This, in turn, has a positive
effect on the babys health.
Since conditions during pregnancy will have long term effects on adult health, moderation should be taken into
account for both dietary and physical activity recommendations. Most importantly, the total recommended
pregnancy weight gain depends on pre-pregnant body weight, and weight issues should be addressed before
pregnancy.
Future Direction for Research

It is reasonable to expect higher weight gain for multiple gestations.[3] Recommendations for women carrying twins
are given but more research should be done to precisely determine the total weight gain, as these ranges are wide.[3]
Also, the ranges for underweight women carrying twins is unknown. There was not enough information to
recommend weight gain cutoffs and guidelines for women carrying three or more babies, women of short stature
(<157 centimetres), and pregnant teens.[3] Estimated energy requirements (EER) for overweight/obese women are
unavailable so more research is needed to evaluate on that.[3]
Practical Advice for Mothers

The following general tips can be helpful to pregnant women. It would be beneficial to maintain adequate physical
activity to meet energy needs from the food consumed.[20] Eating a balanced diet would be optimal for healthy
pregnancy results.[21] To prevent problems like dehydration and constipation, it is important to drink enough fluids,
especially water, to support blood volume increases during pregnancy.[22] It is recommended to accompany regular
meals with a daily prenatal vitamin supplement that has sufficient folic acid and iron content.[20]
If the fetus is predicted to have low birth weight, in addition to the general recommendations, it would be ideal to
increase caloric intake, which can be done by having extra Food Guide Servings daily.[20] If the fetus is predicted to
have high birth weight, smaller and more frequent meals should be consumed to allow better weight management.[23]
Moderate sugar intake, such as fruit juices, is also suggested.[23] It is essential to limit food and beverages with high
calories and salt content.[20]
References
[1] Barr, Susan (2010). FNH 471 Human Nutrition Over the Life Span. Course Notes, Fall. University of British Columbia.
[2] De Leon, Victoria. "Weight Problems During Prengnacy And The Effect On Your Baby" (http:/ / www. toloseweightafterpregnancy. com/
losing-pregnancy-weight-weight-problems-during-pregnancy-and-the-effect-on-your-baby/ ). Losing Pregnancy Weight. . Retrieved 3 March
2011.
[3] "Draft Prenatal Nutrition Guidelines for Health Professionals - Maternal Weight and Weight Gain in Pregnancy" (http:/ / www. hc-sc. gc. ca/
fn-an/ consult/ _matern-weight-poids2009/ draft-ebauche-eng. php). Health Canada. 2009. . Retrieved December 1, 2010.
[4] Bateson, P (2001). "Fetal experience and good adult design". International Journal of Epidemiology 30 (5): 928934.
doi:10.1093/ije/30.5.928.
[5] Barker, DJP (2004). "The Developmental Origins of Adult Disease" (http:/ / www. jacn. org/ cgi/ content/ full/ 23/ suppl_6/ 588S). Journal of
the American College of Nutrition (American College of Nutrition) 23 (6): 588S-595S. .
[6] Byrne, CD; Phillips, DI (2000). "Fetal origins of adult disease: epidemiology and mechanisms". J Clin Pathol 53: 822828.
doi:10.1136/jcp.53.11.822.
[7] Roseboom, Tessa; Rooij, Susanne de; Painter, Rebecca (2006). "The Dutch famine and its long-term consequences for adult health". Early
Human Development (Elsevier Ireland) 82: 485491. doi:10.1016/j.earlhumdev.2006.07.001.
243

[8] Hornstra, Gerard; Uauy, Ricardo; Yang, Xiaoguang (2004). The impact of maternal nutrition on the offspring. New York: Basel.
ISBN380557780X.
[9] 3D Pregnancy (http:/ / www. 3dpregnancy. com/ static/ pregnancy-week-10. html) (Image from gestational age of 10 weeks). Retrieved
2010-12-13. A rotatable 3D version of this photo is available here (http:/ / www. 3dpregnancy. com/ rotatable/ 10-weeks-pregnant. html), and
a sketch is available here (http:/ / www. 3dpregnancy. com/ pictures/ pregnancy-week-10. html).
[12] "Canadian Guidelines for Body Weight Classification in Adults" (http:/ / www. hc-sc. gc. ca/ fn-an/ nutrition/ weights-poids/ guide-ld-adult/
weight_book_tc-livres_des_poids_tm-eng. php). Health Canada. 2003. . Retrieved November 27, 2010.
[13] "Weight Gain During Pregnancy: Reexamining the Guidelines" (http:/ / www. iom. edu/ Reports/ 2009/
Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines. aspx). Institute of Medicine. 2009. . Retrieved November 28, 2010.
[14] Lee, PA; Chernausek, SD; et al. (2003). "International Small for Gestational Age Advisory Board Consensus Development Conference
Statement: Management of Short Children Born Small for Gestational Age, April 24October 1, 2001". PEDIATRICS 111 (6): 12531261.
doi:10.1542/peds.111.6.1253.
[15] "Small for Gestational Age" (http:/ / www. lpch. org/ DiseaseHealthInfo/ HealthLibrary/ hrnewborn/ sga. html), Lucile Packard Children's
Hospital, 2010. Retrieved 2010-11-09.
[16] Merialdi, M; Carroli, G; et al. (2003). "Nutritional Interventions during Pregnancy for the Prevention or Treatment of Impaired Fetal
Growth: An Overview of Randomized Controlled Trials" (http:/ / jn. nutrition. org/ content/ 133/ 5/ 1626S. full. pdf+ html). The Journal of
Nutrition 133 (5): 1626S-1631S. .
[17] Lisa Gourley, "Prenatal Nutrition" (http:/ / www. healthline. com/ galecontent/ prenatal-nutrition/ 4), Healthline Networks, Inc., 2002.
[18] Children's Hospital of Wisconsin, "Large for Gestational Age" (http:/ / www. chw. org/ display/ PPF/ DocID/ 23374/ router. asp), Children's
Hospital and Health System, 2010. Retrieved 2010-11-09.
[19] BabyCenter Medical Advisory Board, "Labor complication: Big baby (macrosomia)" (http:/ / www. babycenter. com/
0_labor-complication-big-baby-macrosomia_1152319. bc), BabyCenter, L.L.C., 2006. Retrieved 2010-11-05.
[20] "Prenatal Nutrition Guidelines for Health Professionals - Background on Canada's Food Guide" (http:/ / www. hc-sc. gc. ca/ fn-an/ pubs/
nutrition/ guide-prenatal-eng. php), Health Canada, 2009. Retrieved 2010-11-23.
[21] Larissa Hirsch, "Staying Healthy During Pregnancy" (http:/ / kidshealth. org/ parent/ pregnancy_center/ your_pregnancy/ preg_health.
html?tracking=P_RelatedArticle#), The Nemours Foundation, 2008. Retrieved 2010-11-17.
[22] Ministry of Health Promotion, "The Juicy Story on Drinks" (http:/ / www. eatrightontario. ca/ en/ ViewDocument. aspx?id=72& Topic=5&
Cat=162), Queen's Printer for Ontario, 2010. Retrieved 2010-11-18.
[23] Alberta clinical experts, "Prediabetes or Impaired Glucose Intolerance" (http:/ / www. capitalhealth. ca/ EspeciallyFor/ WeightWise/
Prediabetes_Impaired_Glucose_Tolerance_Adults. htm), HealthLink Alberta, 2008. Retrieved 2010-11-21.
244
Anxiety
245
Anxiety
Anxiety
A marble bust of the Roman Emperor Decius from the Capitoline Museum. This portrait "conveys an impression of anxiety and weariness, as of a
[1]
man shouldering heavy [state] responsibilities."
MeSH
D001007
[2]
Anxiety (also called angst or worry) is a psychological and physiological state characterized by somatic, emotional,
cognitive, and behavioral components.[3] The root meaning of the word anxiety is 'to vex or trouble'; in either
presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness, and dread.[4]
Anxiety is considered to be a normal reaction to a stressor. It may help an individual to deal with a demanding
situation by prompting them to cope with it. When anxiety becomes excessive, it may fall under the classification of
an anxiety disorder.[5]
Description
Anxiety is a generalized mood condition that can occur without an identifiable triggering stimulus. As such, it is
distinguished from fear, which is an appropriate emotional response to a perceived threat. Additionally, fear is
related to the specific behaviors of escape and avoidance, whereas anxiety is related to situations perceived as
uncontrollable or unavoidable.[6] Another view defines anxiety as "a future-oriented mood state in which one is
ready or prepared to attempt to cope with upcoming negative events",[7] suggesting that it is a distinction between
future vs. present dangers which divides anxiety and fear. In a 2011 review of the literature,[8] fear and anxiety were
said to be differentiated in four domains: (1) duration of emotional experience, (2) temporal focus, (3) specificity of
the threat, and (4) motivated direction. Fear was defined as short lived, present focused, geared towards a specific
threat, and facilitating escape from threat; while anxiety was defined as long acting, future focused, broadly focused
towards a diffuse threat, and promoting caution while approaching a potential threat.
The physical effects of anxiety may include heart palpitations, tachycardia, muscle weakness and tension, fatigue,
nausea, chest pain, shortness of breath, stomach aches, or headaches. As the body prepares to deal with a threat,
blood pressure, heart rate, perspiration, blood flow to the major muscle groups are increased, while immune and
digestive functions are inhibited (the fight or flight response). External signs of anxiety may include pallor, sweating,
trembling, and pupillary dilation. Someone who has anxiety might also experience it subjectively as a sense of dread
Anxiety
or panic.
Although panic attacks are not experienced by every person who has anxiety, they are a common symptom. Panic
attacks usually come without warning and although the fear is generally irrational, the subjective perception of
danger is very real. A person experiencing a panic attack will often feel as if he or she is about to die or lose
consciousness.
The emotional effects of anxiety may include "feelings of apprehension or dread, trouble concentrating, feeling
tense or jumpy, anticipating the worst, irritability, restlessness, watching (and waiting) for signs (and occurrences) of
danger, and, feeling like your mind's gone blank"[9] as well as "nightmares/bad dreams, obsessions about sensations,
deja vu, a trapped in your mind feeling, and feeling like everything is scary."[10]
The cognitive effects of anxiety may include thoughts about suspected dangers, such as fear of dying. "You may...
fear that the chest pains are a deadly heart attack or that the shooting pains in your head are the result of a tumor or
aneurysm. You feel an intense fear when you think of dying, or you may think of it more often than normal, or cant
get it out of your mind."[11]
The behavioral effects of anxiety may include withdrawal from situations which have provoked anxiety in the
past.[12] Anxiety can also be experienced in ways which include changes in sleeping patterns, nervous habits, and
increased motor tension like foot tapping.[12]
Causes
An evolutionary psychology explanation is that increased anxiety serves the purpose of increased vigilance regarding
potential threats in the environment as well as increased tendency to take proactive actions regarding such possible
threats. This may cause false positive reactions but also avoid real threats. This may explain why anxious people are
less likely to die due to accidents.[13]
The psychologist David H. Barlow of Boston University conducted a study that showed three common
characteristics of people suffering from chronic anxiety, which he characterized as "a generalized biological
vulnerability," "a generalized psychological vulnerability," and "a specific psychological vulnerability."[14] While
chemical issues in the brain that result in anxiety (especially resulting from genetics) are well documented, this study
highlights an additional environmental factor that may result from being raised by parents suffering from chronic
anxiety themselves.
Research upon adolescents who as infants had been highly apprehensive, vigilant, and fearful finds that their nucleus
accumbens is more sensitive than that in other people when selecting to make an action that determined whether they
received a reward.[15] This suggests a link between circuits responsible for fear and also reward in anxious people.
As researchers note "a sense of responsibility, or self agency, in a context of uncertainty (probabilistic outcomes)
drives the neural system underlying appetitive motivation (i.e., nucleus accumbens) more strongly in
temperamentally inhibited than noninhibited adolescents."[15]
Neural circuitry involving the amygdala and hippocampus is thought to underlie anxiety.[16] When people are
confronted with unpleasant and potentially harmful stimuli such as foul odors or tastes, PET-scans show increased
bloodflow in the amygdala.[17] [18] In these studies, the participants also reported moderate anxiety. This might
indicate that anxiety is a protective mechanism designed to prevent the organism from engaging in potentially
harmful behaviors.
Although single genes have little effect on complex traits and interact heavily both between themselves and with the
external factors, research is underway to unravel possible molecular mechanisms underlying anxiety and comorbid
conditions. One candidate gene with polymorphisms that influence anxiety is PLXNA2.[19]
246
Anxiety
Varieties
In Medicine
Anxiety can be a symptom of an underlying health issue such as chronic obstructive pulmonary disease (COPD),
heart failure, or heart arrythmia.[20]
Abnormal and pathological anxiety or fear may itself be a medical condition falling under the blanket term "anxiety
disorder". Such conditions came under the aegis of psychiatry at the end of the 19th century[21] and current
psychiatric diagnostic criteria recognize several specific forms of the disorder. Recent surveys have found that as
many as 18% of Americans may be affected by one or more of them.[22]
Standardized screening tools such as Zung Self-Rating Anxiety Scale, Beck Anxiety Inventory, and HAM-A
(Hamilton Anxiety Scale) can be used to detect anxiety symptoms and suggest the need for a formal diagnostic
assessment of anxiety disorder.[23] The HAM-A (Hamilton Anxiety Scale) measures the severity of a patient's
anxiety, based on 14 parameters, including anxious mood, tension, fears, insomnia, somatic complaints and behavior
at the interview.[24]
Existential Anxiety
Further information: Angst,Existential crisis,andNihilism
The philosopher Sren Kierkegaard, in The Concept of Anxiety, described anxiety or dread associated with the
"dizziness of freedom" and suggested the possibility for positive resolution of anxiety through the self-conscious
exercise of responsibility and choosing. In Art and Artist (1932), the psychologist Otto Rank wrote that the
psychological trauma of birth was the pre-eminent human symbol of existential anxiety and encompasses the
creative person's simultaneous fear of and desire for separation, individuation and differentiation.
The theologian Paul Tillich characterized existential anxiety[25] as "the state in which a being is aware of its possible
nonbeing" and he listed three categories for the nonbeing and resulting anxiety: ontic (fate and death), moral (guilt
and condemnation), and spiritual (emptiness and meaninglessness). According to Tillich, the last of these three types
of existential anxiety, i.e. spiritual anxiety, is predominant in modern times while the others were predominant in
earlier periods. Tillich argues that this anxiety can be accepted as part of the human condition or it can be resisted
but with negative consequences. In its pathological form, spiritual anxiety may tend to "drive the person toward the
creation of certitude in systems of meaning which are supported by tradition and authority" even though such
"undoubted certitude is not built on the rock of reality".
According to Viktor Frankl, the author of Man's Search for Meaning, when a person is faced with extreme mortal
dangers, the most basic of all human wishes is to find a meaning of life to combat the "trauma of nonbeing" as death
is near.
Test and Performance Anxiety

According to Yerkes-Dodson law, an optimal level of arousal is necessary to best complete a task such as an exam,
performance, or competitive event. However, when the anxiety or level of arousal exceeds that optimum, the result is
a decline in performance.
Test anxiety is the uneasiness, apprehension, or nervousness felt by students who had a fear of failing an exam.
Students who have test anxiety may experience any of the following: the association of grades with personal worth;
fear of embarrassment by a teacher; fear of alienation from parents or friends; time pressures; or feeling a loss of
control. Sweating, dizziness, headaches, racing heartbeats, nausea, fidgeting, and drumming on a desk are all
common. Because test anxiety hinges on fear of negative evaluation, debate exists as to whether test anxiety is itself
a unique anxiety disorder or whether it is a specific type of social phobia.
247
Anxiety
While the term "test anxiety" refers specifically to students, many workers share the same experience with regard to
their career or profession. The fear of failing at a task and being negatively evaluated for failure can have a similarly
negative effect on the adult.
Stranger and Social Anxiety

Anxiety when meeting or interacting with unknown people is a common stage of development in young people. For
others, it may persist into adulthood and become social anxiety or social phobia. "Stranger anxiety" in small children
is not considered a phobia. In adults, an excessive fear of other people is not a developmentally common stage; it is
called social anxiety. According to Cutting,[26] social phobics do not fear the crowd but the fact that they may be
being judged negatively.
Social anxiety varies in degree and severity. Whilst for some people it is characterized by experiencing discomfort or
awkwardness during physical social contact (Embracing, Shaking Hands, etc.), in other cases it can lead to a fear of
interacting with unfamiliar people altogether. There can be a tendency among those suffering from this condition to
restrict their lifestyles to accommodate the anxiety, minimizing social interaction whenever possible. Social Anxiety
also forms a core aspect of certain personality disorders, including Avoidant Personality Disorder.
Generalized Anxiety
Further information: Generalized anxiety disorderandCognitive behavioral therapy
Overwhelming anxiety, if not treated early, can consequently become a generalized anxiety disorder (GAD), which
can be identified by symptoms of exaggerated and excessive worry, chronic anxiety, and constant, irrational
thoughts. The anxious thoughts and feelings felt while suffering from GAD are difficult to control and can cause
serious mental anguish that interferes with normal, daily functioning.[27]
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) includes specific criteria for diagnosing
generalized anxiety disorder. The DSM-IV states that a patient must experience chronic anxiety and excessive worry,
almost daily, for at least 6 months due to a number of stressors (such as work or school) and experience three or
more defined symptoms, including, restlessness or feeling keyed up or on edge, being easily fatigued, difficulty
concentrating or mind going blank, irritability, muscle tension, sleep disturbance (difficulty falling or staying asleep,
or restless unsatisfying sleep).[28]
If symptoms of chronic anxiety are not addressed and treated in adolescence then the risk of developing an anxiety
disorder in adulthood increases significantly.[29] Clinical worry is also associated with risk of comorbidity with
other anxiety disorders and depression which is why immediate treatment is so important.[30]
Generalized anxiety disorder can be treated through specialized therapies aimed at changing thinking patterns and in
turn reducing anxiety-producing behaviors. Cognitive behavioral therapy (CBT) and short-term psychodynamic
psychotherapy (STPP) can be used to successfully treat GAD with positive effects lasting 12 months after
treatment.[31] There are also other treatment plans that should be discussed with a knowledgeable health care
practitioner, which can be used in conjunction with behavioral therapy to greatly reduce the disabling symptoms of
generalized anxiety disorder.
248
Anxiety
249
Trait Anxiety
Anxiety can be either a short term 'state' or a long term "trait." Trait anxiety reflects a stable tendency to respond
with state anxiety in the anticipation of threatening situations.[32] It is closely related to the personality trait of
neuroticism. Such anxiety may be conscious or unconscious.[33]
Choice or Decision Anxiety

Anxiety induced by the need to choose between similar options is increasingly being recognized as a problem for
individuals and for organisations:[34] [35]
"Today were all faced with greater choice, more competition and less time to consider our options or
seek out the right advice."[36]
Paradoxical Anxiety
Further information: Adverse effects of meditation
Paradoxical anxiety is anxiety arising from use of methods or techniques which are normally used to reduce anxiety.
This includes relaxation or meditation techniques[37] as well as use of certain medications.[38] In some Buddhist
meditation literature, this effect is described as something which arises naturally and should be turned toward and
mindfully explored in order to gain insight into the nature of emotion, and more profoundly, the nature of self.[39]
Positive Psychology
Further information: Mental state
In Positive psychology, anxiety is described as the mental state that results from a difficult challenge for which the
subject has insufficient coping skills.[40]
See Also
Arousal
Catastrophization
Panic attack
Paranoia
Social anxiety
External Links
Anxiety [41] at the Open Directory Project
Social Anxiety [42] at the Open Directory Project
Psychology Tools [43]: Anxiety support forum
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[37] Bourne, Edmund J. (2005). The anxiety & phobia workbook (4th ed.). New Harbinger Publications. p.369. ISBN1572244135.
[38] Heide, Frederick J.; Borkovec, T. D. (1983). "Relaxation-Induced Anxiety: Paradoxical Anxiety Enhancement Due to Relaxation Training".
Journal of Consulting and Clinical Psychology 51 (2): 17182. doi:10.1037/0022-006X.51.2.171. PMID6341426.
[39] Gunaratana, Henepola. "Mindfullness in Plain English - The threefold Guidance" (http:/ / www. urbandharma. org/ udharma4/ mpe9. html). .
[40] Csikszentmihalyi, M., Finding Flow, 1997
[41] http:/ / www. dmoz. org/ Health/ Mental_Health/ Disorders/ Anxiety/ Support_Groups/
[42] http:/ / www. dmoz. org/ Health/ Mental_Health/ Disorders/ Anxiety/ Social_Anxiety/
[43] http:/ / psychology-tools. com/ forum/ forumdisplay. php?25-Anxiety
Emotional dysregulation
Emotional dysregulation (ED) is a term used in the mental health community to refer to an emotional response that
is poorly modulated, and does not fall within the conventionally accepted range of emotive response. ED may be
referred to as labile mood[1] or mood swings.
Possible manifestations of emotional dysregulation include angry outbursts or behavior outbursts such as destroying
or throwing objects, aggression towards self or others, and threats to kill oneself. These variations usually occur in
seconds to minutes or hours. Emotional dysregulation can lead to behavioral problems and can interfere with a
person's social interactions and relationships at home, in school, or at place of employment.
Emotional dysregulation can be associated with an experience of early psychological trauma, brain injury, or chronic
maltreatment (such as child abuse, child neglect, or institutional neglect/abuse), and associated disorders such as
reactive attachment disorder.[2] Emotional dysregulation may present in people with psychiatric disorders such as
bipolar disorder, borderline personality disorder, and Complex post-traumatic stress disorder.[3] [4] ED is also found
among those with autism spectrum disorders, including Asperger syndrome.[3]
Etymology
The word dysregulation is a neologism created by combining the prefix "dys" to "regulation" According to
Webster's, dys has various roots. With Latin and Greek roots, it is akin to Old English t-, te- apart and in Sanskrit
dus- bad, difficult.
References
[1] Beauchaine, T., Gatzke-Kopp, L., Mead, H., (2007). Polyvagal Theory and developmental psychopathology: Emotion dysregulation and
conduct problems from preschool to adolescence. Biological Psychology, 74, 174-184.
[2] Daniel Schechter, Erica Willheim (2009). Disturbances of attachment and parental psychopathology in early childhood. Infant and Early
Childhood Mental Health Issue. Child and Adolescent Psychiatry Clinics of North America, 18(3), 665-687.
[3] Pynoos, R., Steinberg, A., & Piacentini, J. (1999), Bipolar Disorder, and Asperger Syndrome. A developmental psychopathology model of
childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46, 1542-1554.
[4] Schore, A., (2003). Affect dysregulation and disorders of the self. New York: Norton.
251
252

Posttraumatic Stress Disorder
Classification and external resources
No quieren (They do not want to)

#9 from aquatint series Los Desastres de la Guerra (The disasters of war 1810-1820)
Francisco Goya (1746-1828)
[1]
ICD-10
F43.1
ICD-9
309.81
DiseasesDB
33846
MedlinePlus
000925
eMedicine
med/1900
MeSH
D013313
[2]
[3]
[4]
[5]
[6]
Posttraumatic[7] stress disorder (PTSD) is a severe anxiety disorder that can develop after exposure to any event
that results in psychological trauma.[8] [9] [10] This event may involve the threat of death to oneself or to someone
else, or to one's own or someone else's physical, sexual, or psychological integrity,[8] overwhelming the individual's
ability to cope. As an effect of psychological trauma, PTSD is less frequent and more enduring than the more
commonly seen acute stress response. Diagnostic symptoms for PTSD include re-experiencing the original trauma(s)
through flashbacks or nightmares, avoidance of stimuli associated with the trauma, and increased arousal such as
difficulty falling or staying asleep, anger, and hypervigilance. Formal diagnostic criteria (both DSM-IV-TR and
ICD-10) require that the symptoms last more than one month and cause significant impairment in social,
occupational, or other important areas of functioning.[8]
Classification
Posttraumatic stress disorder is classified as an anxiety disorder, characterized by aversive anxiety-related
experiences, behaviors, and physiological responses that develop after exposure to a psychologically traumatic event
(sometimes months after). Its features persist for longer than 30 days, which distinguishes it from the briefer acute
stress disorder. These persisting posttraumatic stress symptoms cause significant disruptions of one or more
important areas of life function.[11] It has three sub-forms: acute, chronic, and delayed-onset.[12]
Causes
Psychological trauma
PTSD is believed to be caused by either physical trauma or psychological trauma, or more frequently a combination
of both.[8] According to Atkinson et al. (2000) PTSD is more likely to be caused by physical or psychological trauma
caused by humans such as rape, war, or terrorist attack than by trauma caused by natural disasters. Possible
sources of trauma include experiencing or witnessing childhood or adult physical, emotional or sexual abuse.[8] In
addition, experiencing or witnessing an event perceived as life-threatening such as physical assault, adult
experiences of sexual assault, accidents, drug addiction, illnesses, medical complications, or employment in
occupations exposed to war (such as soldiers) or disaster (such as emergency service workers).[13]
Traumatic events that may cause PTSD symptoms to develop include violent assault, kidnapping, sexual assault,
torture, being a hostage, prisoner of war or concentration camp victim, experiencing a disaster, violent automobile
accidents or getting a diagnosis of a life-threatening illness.[8] Children or adults may develop PTSD symptoms by
experiencing bullying or mobbing.[14] [15] Approximately 25% of children exposed to family violence can experience
PTSD.[16] Preliminary research suggests that child abuse may interact with mutations in a stress-related gene to
increase the risk of PTSD in adults.[17] [18] [19]
Multiple studies show that parental PTSD and other posttraumatic disturbances in parental psychological functioning
can, despite a traumatized parent's best efforts, interfere with their response to their child as well as their child's
response to trauma.[20] [21] Parents with violence-related PTSD may, for example, inadvertently expose their children
to developmentally inappropriate violent media due to their need to manage their own emotional dysregulation.[22]
Clinical findings indicate that a failure to provide adequate treatment to children after they suffer a traumatic
experience, depending on their vulnerability and the severity of the trauma, will ultimately lead to PTSD symptoms
in adulthood.[23]
Evolutionary psychology
Evolutionary psychology views different types of fears and reactions caused by fears as adaptations that may have
been useful in the ancestral environment in order to avoid or cope with various threats. Mammals generally display
several defensive behaviors roughly dependent on how close the threat is: avoidance, vigilant immobility,
withdrawal, aggressive defense, appeasement, and finally complete frozen immobility (the last possibly to confuse a
predator's attack reflex or to simulate a dead and contaminated body). PTSD may correspond to and be caused by
overactivation of such fear circuits. Thus, PTSD avoidance behaviors may correspond to mammal avoidance of and
withdrawal from threats. Heightened memory of past threats may increase avoidance of similar situations in the
future as well as be a prerequisite for analyzing the past threat and develop better defensive behaviors if the threat
should reoccur. PTSD hyperarousal may correspond to vigilant immobility and aggressive defense. Complex
post-traumatic stress disorder (and phenomena such as the Stockholm syndrome) may in part correspond to the
appeasement stage and possibly the frozen immobility stage.[24] [25]
There may be evolutionary explanations for differences in resilience to traumatic events. Thus, PTSD is rare
following traumatic fire which may be explained by events such as forest fires long being part of the evolutionary
history of mammals. On the other hand, PTSD is much more common following modern warfare, which may be
253
254
explained by modern warfare being a new development and very unlike the quick inter-group raids that are argued to
have characterized the paleolithic.[26]
Neuroendocrinology
PTSD symptoms may result when a traumatic event causes an over-reactive adrenaline response, which creates deep
neurological patterns in the brain. These patterns can persist long after the event that triggered the fear, making an
individual hyper-responsive to future fearful situations.[27]
PTSD displays biochemical changes in the brain and body that differ from other psychiatric disorders such as major
depression. Individuals diagnosed with PTSD respond more strongly to a dexamethasone suppression test than
individuals diagnosed with clinical depression.[28] [29]
In addition, most people with PTSD also show a low secretion of cortisol and high secretion of catecholamines in
urine, with a norepinephrine/cortisol ratio consequently higher than comparable non-diagnosed individuals.[30] This
is in contrast to the normative fight-or-flight response, in which both catecholamine and cortisol levels are elevated
after exposure to a stressor.[31]
Brain catecholamine levels are high,[32] and corticotropin-releasing factor (CRF) concentrations are high.[33]
Together, these findings suggest abnormality in the hypothalamic-pituitary-adrenal (HPA) axis.
[34]
Given the strong cortisol suppression to dexamethasone in PTSD, HPA axis abnormalities are likely predicated on
strong negative feedback inhibition of cortisol, itself likely due to an increased sensitivity of glucocorticoid
receptors.[35] Some researchers have associated the response to stress in PTSD with long-term exposure to high
levels of norepinephrine and low levels of cortisol, a pattern associated with improved learning in animals.
Translating this reaction to human conditions gives a pathophysiological explanation for PTSD by a maladaptive
learning pathway to fear response through a hypersensitive, hyperreactive and hyperresponsive HPA axis.[36]
Low cortisol levels may predispose individuals to PTSD: Following war trauma, Swedish soldiers serving in Bosnia
and Herzegovina with low pre-service salivary cortisol levels had a higher risk of reacting with PTSD symptoms,
following war trauma, than soldiers with normal pre-service levels.[37] Because cortisol is normally important in
restoring homeostasis after the stress response, it is thought that trauma survivors with low cortisol experience a
poorly containedthat is, longer and more distressingresponse, setting the stage for PTSD.
However, there is considerable controversy within the medical community regarding the neurobiology of PTSD. A
review of existing studies on this subject showed no clear relationship between cortisol levels and PTSD. Only a
slight majority have found a decrease in cortisol levels while others have found no effect or even an increase.[38]
255
Neuroanatomy
Three areas of the brain whose function may be altered in
PTSD have been identified: the prefrontal cortex, amygdala
and hippocampus. Much of this research has utilised PTSD
victims from the Vietnam War. For example, a prospective
study using the Vietnam Head Injury Study showed that
damage to the prefrontal cortex may actually be protective
against later development of PTSD.[40] In a study by Gurvits
et al., combat veterans of the Vietnam War with PTSD
showed a 20% reduction in the volume of their hippocampus
compared with veterans who suffered no such symptoms.[41]
This finding could not be replicated in chronic PTSD patients
traumatized at an air show plane crash in 1988 (Ramstein,
Germany).[42] [43]
In human studies, the amygdala has been shown to be strongly
involved in the formation of emotional memories, especially
fear-related memories. Neuroimaging studies in humans have
revealed both morphological and functional aspects of PTSD.
Regions of the brain associated with stress and posttraumatic

[39]
stress disorder
The amygdalocentric model of PTSD proposes that it is associated with hyperarousal of the amygdala and
insufficient top-down control by the medial prefrontal cortex and the hippocampus particularly during extinction.[44]
This is consistent with an interpretation of PTSD as a syndrome of deficient extinction ability.[44] [45] A study at the
European Neuroscience Institute-Goettingen (Germany) found that fear extinction-induced IGF2/IGFBP7 signalling
promotes the survival of 1719-day-old newborn hippocampal neurons. This suggests that therapeutic strategies that
enhance IGF2 signalling and adult neurogenesis might be suitable to treat diseases linked to excessive fear memory
such as PTSD.[46] Further animal and clinical research into the amygdala and fear conditioning may suggest
additional treatments for the condition.
Genetics
There is evidence that susceptibility to PTSD is hereditary. For twin pairs exposed to combat in Vietnam, having a
monozygotic (identical) twin with PTSD was associated with an increased risk of the co-twin having PTSD
compared to twins that were dizygotic (non-identical twins).[47]
Recently, it has been found that several single-nucleotide polymorphisms (SNPs) in FK506 binding protein 5
(FKBP5) interact with childhood trauma to predict severity of adult PTSD.[48] [49] These findings suggest that
individuals with these SNPs who are abused as children are more susceptible to PTSD as adults.
This is particularly interesting given that FKBP5 SNPs have previously been associated with peritraumatic
dissociation (that is, dissociation at the time of the trauma),[50] which has itself been shown to be predictive of
PTSD.[51] [52] Furthermore, FKBP5 may be less expressed in those with current PTSD.[53] Another recent study
found a single SNP in a putative estrogen response element on ADCYAP1R1 (encodes pituitary adenylate
cyclase-activating polypeptide type I receptor or PAC1) to predict PTSD diagnosis and symptoms in females.[54]
Incidentally, this SNP is also associated with fear discrimination. The study suggests that perturbations in the
PACAP-PAC1 pathway are involved in abnormal stress responses underlying PTSD.
Risk factors
Although most people (50-90%) encounter trauma over a lifetime,[55] [56] only about 8% develop full PTSD.[55]
Vulnerability to PTSD presumably stems from an interaction of biological diathesis, early childhood developmental
experiences, and trauma severity.
Predictor models have consistently found that childhood trauma, chronic adversity, and familial stressors increase
risk for PTSD as well as risk for biological markers of risk for PTSD after a traumatic event in adulthood.[57] [58] [59]
[60]
This effect of childhood trauma, which is not well understood, may be a marker for both traumatic experiences
and attachment problems.[61] [62] Proximity to, duration of, and severity of the trauma also make an impact; and
interpersonal traumas cause more problems than impersonal ones.[63]
Military experience
Schnurr, Lunney, and Sengupta[52] identified risk factors for the development of PTSD in Vietnam veterans. Among
those are:
Hispanic ethnicity, coming from an unstable family, being punished severely during childhood, childhood asocial
behavior and depression as pre-military factors
War-zone exposure, peritraumatic dissociation, depression as military factors
Recent stressful life events, post-Vietnam trauma and depression as post-military factors
They also identified certain protective factors, such as:
Japanese-American ethnicity, high school degree or college education, older age at entry to war, higher
socioeconomic status and a more positive paternal relationship as pre-military protective factors
Social support at homecoming and current social support as post-military factors.[64] Other research also indicates
the protective effects of social support in averting PTSD or facilitating recovery if it develops.[65] [66]
There may also be an attitudinal component; for example, a soldier who believes that they will not sustain injuries
may be more likely to develop symptoms of PTSD than one who anticipates the possibility, should either be
wounded. Likewise, the later incidence of suicide among those injured in home fires above those injured in fires in
the workplace suggests this possibility.
Foster care
In the Casey Family Northwest Alumni Study, conducted in conjunction with researchers from the Harvard Medical
School in Oregon and Washington state, the rate of PTSD in adults who were in foster care for one year between the
ages of 14-18 was found to be higher than that of combat veterans. Up to 25 percent of those in the study meet the
diagnostic criteria for PTSD as compared to 12-13 percent of Iraq war veterans and 15 percent of Vietnam War
veterans, and a rate of 4 percent in the general population. The recovery rate for foster home alumni was 28.2% as
opposed to 47% in the general population.[67] [68]
Dubner and Motta (1999)[69] found that 60% of children in foster care who had experienced sexual abuse had PTSD,
and 42% of those who had been physically abused met the PTSD criteria. PTSD was also found in 18% of the
children who were not abused. These children may have developed PTSD due to witnessing violence in the home, or
as a result of real or perceived parental abandonment.
256
Diagnosis
Criteria
The diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental Disorders IV (Text
Revision) (DSM-IV-TR), may be summarized as:[8] [70]
A: Exposure to a traumatic event
This must have involved both (a) loss of "physical integrity", or risk of serious injury or death, to self or others, and
(b) a response to the event that involved intense fear, horror or helplessness (or in children, the response must
involve disorganized or agitated behavior). (The DSM-IV-TR criterion differs substantially from the previous
DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause "significant
symptoms of distress in almost anyone," and that the event was "outside the range of usual human experience."[71] )
B: Persistent re-experiencing
One or more of these must be present in the victim: flashback memories, recurring distressing dreams, subjective
re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any
objective or subjective reminder of the traumatic event(s).
C: Persistent avoidance and emotional numbing
This involves a sufficient level of:
avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s);
avoidance of behaviors, places, or people that might lead to distressing memories;
inability to recall major parts of the trauma(s), or decreased involvement in significant life activities;
decreased capacity (down to complete inability) to feel certain feelings;
an expectation that one's future will be somehow constrained in ways not normal to other people.
D: Persistent symptoms of increased arousal not present before

These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger,
concentration, or hypervigilance.
E: Duration of symptoms for more than 1 month
If all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with Acute stress disorder.
F: Significant impairment
The symptoms reported must lead to "clinically significant distress or impairment" of major domains of life activity,
such as social relations, occupational activities, or other "important areas of functioning".[72]
Assessment
Since the introduction of DSM-IV, the number of possible events which might be used to diagnose PTSD has
increased; one study suggests that the increase is around 50%.[73] Various scales exist to measure the severity and
frequency of PTSD symptoms.[74] [75] Standardized screening tools such as Trauma Screening Questionnaire[76] and
PTSD Symptom Scale[77] can be used to detect possible symptoms of posttraumatic stress disorder, and suggest the
need for a formal diagnostic assessment.
257
Research-based alternative symptom groups

Emerging factor analytic research[78] suggests that PTSD symptoms group empirically into four clusters, not the
three currently described in the Diagnostic and Statistical Manual of Mental Disorders. One model supported by this
research divides the traditional avoidance symptoms into a cluster of numbing symptoms (such as loss of interest and
feeling emotionally numb) and a cluster of behavioral avoidance symptoms (such as avoiding reminders of the
trauma).[79] An alternative model adds a fourth cluster of dysphoric symptoms. These include symptoms of
emotional numbing, as well as anger, sleep disturbance, and difficulty concentrating (traditionally grouped under the
hyperarousal cluster).[80] [81] A literature review [82] and meta-analysis [83] did not find strong support across the
literature for one of these models over the other.
DSM-5 proposed diagnostic criteria changes

In preparation for the May 2013[84] release of the DSM-5,[85] the fifth version of the American Psychiatric
Association's diagnostic manual, draft diagnostic criteria was released for public comment, followed by a two-year
period of field testing.[86] Proposed changes to the criteria (subject to ongoing review[87] and research[88] ) include
the following [89] :
Criterion A (prior exposure to traumatic events) is more specifically stated, and evaluation of an individual's
emotional response at the time (current criterion A2) is dropped.
Several items in Criterion B (intrusion symptoms) are rewritten to add or augment certain distinctions now
considered important.
Special consideration is given to developmentally appropriate criteria for use with children and adolescents. This
is especially evident in the restated Criterion B - intrusion symptoms. Development of age-specific criteria for
diagnosis of PTSD is ongoing at this time.
Criterion C (avoidance and numbing) has been split into "C" and "D":
Criterion C (new version) now focuses solely on avoidance of behaviors or physical or temporal reminders of
the traumatic experience(s). What were formerly two symptoms are now three, due to slight changes in
descriptions.
New Criterion D focuses on negative alterations in cognition and mood associated with the traumatic event(s),
and contains two new symptoms, one expanded symptom, and four largely unchanged symptoms specified in
the previous criteria.
Criterion E (formerly "D"), which focuses on increased arousal and reactivity, contains one modestly revised, one
entirely new, and four unchanged symptoms.
Criterion F (formerly "E") still requires duration of symptoms to have been at least one month.
Criterion G (formerly "F") stipulates symptom impact ("disturbance") in the same way as before.
The "acute" vs "delayed" distinction is dropped; the "delayed" specifier is considered appropriate if clinical
symptom onset is no sooner than 6 months after the traumatic event(s).
"Developmental trauma disorder", a proposed new diagnosis, was still under discussion at the time of the draft
publication.[90]
258
Public policy response

In recent history, catastrophes (by human means or not) such as
the 2004 Indian Ocean tsunami may have caused PTSD in many
survivors and rescue workers. Today relief workers from
organizations such as the Red Cross and the Salvation Army
provide counseling after major disasters as part of their standard
procedures to curb severe cases of posttraumatic stress disorder.
United States - veterans
Further information: Benefits for US Veterans with PTSD
A review of the provision of compensation to veterans for PTSD
by the United States Department of Veterans Affairs began in
2005 after the VA had noted a 30% increase in PTSD claims in
recent years.[91] In 2005 the suicide rate among male Veteran VA
users was 37.19 per 100,000, compared to 13.59 in females.[92]
This led to a backlash from veterans'-rights groups, and to some
highly publicized suicides by veterans who feared losing their
benefits, which in some cases constituted their only income. In
Vietnam Veterans Memorial, Washington, D.C.
response, on November 10, 2005, the Secretary of Veterans
Affairs announced that "the Department of Veterans Affairs (VA) will not review the files of 72,000 veterans
currently receiving disability compensation for posttraumatic stress disorder..."[93]
The diagnosis of PTSD in U.S. military veterans has been a subject of some controversy due to uncertainties in
objectively diagnosing PTSD in those who may have been exposed to trauma, and due to this diagnosis' association
with some incidence of compensation-seeking behavior.[94] [95]
Many veterans of the wars in Iraq and Afghanistan returning home have faced significant physical, emotional and
relational disruptions. In response, the United States Marine Corps has instituted programs to assist them in
re-adjusting to civilian life, especially in their relationships with spouses and loved ones, to help them communicate
better and understand what the other has gone through.[96] Walter Reed Army Institute of Research (WRAIR)
developed the Battlemind program to assist service members avoid or ameliorate PTSD and related problems.
Other countries - veterans
In the UK, there has been some controversy that National Health Service is dumping veterans on service charities
like Combat Stress.[97] [98] [99]
Veterans Affairs Canada offers a new program that includes rehabilitation, financial benefits, job placement, health
benefits program, disability awards and family support.[100]
Management
Prevention and early intervention strategies
Modest benefits have been seen from early access to cognitive behavioral therapy, as well as from some medications
such as propranolol.[101] Critical incident stress management has been suggested as a means of preventing PTSD but
subsequent studies suggest the likelihood of its producing iatrogenic outcomes.[102] [103] A review of multiple studies
confirmed the finding of no benefit to trauma survivors from single-session early-response interventions, as well as a
failure of blanket multiple-session prevention interventions to yield a benefit to all participants (some were even
harmed).[104]
259

Early detection
The ability to prescreen individuals would be of great help in getting treatment to those who are at risk of PTSD
prior to development of the syndrome. Several biological indicators have been identified that are related to later
PTSD development. First, Delhanty [105] found that higher response times and a smaller hippocampal volume were
identified as linked to later PTSD development. However, both of these indicators are relatively difficult to test for
and need specialized tests and or equipment to identify. A blood biomarker is much easier to test for. Van Zuiden et
al.[106] found just such a biomarker when testing U.S. Army soldiers prior to deployment. They found that soldiers
with more glucocorticoid receptors (GR) were more likely to be diagnosed with PTSD six months after deployment.
However, higher GR levels have not been identified as a cause of PTSD, and may instead be an intermediator, or
even an indicator that the individual has previously experienced traumatic events. There is a great deal of overlap
between high GR levels and those who later are diagnosed with and without PTSD. Thus, the identification of high
GR is simply a vulnerability indicator at this time.
Delhanty [105] found that biological precursors existed directly following traumatic exposure in those who later
developed chronic PTSD and were significantly different from those who did not. Directly following the traumatic
event later sufferers often have significantly lower levels of hypothalamic pituitary-adrenal activity and a
corresponding decrease in Cortisol. Other methods of early detection include the identification of specific risk
factors associated with later PTSD symptoms. Resnick, Acierno, Holmes, Kilpatrick, and Jager [107] for example
were able to identify that the forensic exam given to victims after a rape was associated with PTSD. Finally, global
treatments attempt to avoid the problems of early detection by simply treating everyone involved. However, many
studies [105] have found this to be often ineffective and for global treatments to at times increase prevalence rates of
PTSD.
Preventive Treatments
Psychological debriefing
The first form of preventive treatment is that of a psychological debriefing.[101] Psychological debriefing is the most
often used preventive measure. One of the main reasons for this is the relative ease with which this treatment can be
given to individuals directly following an event. It consists of interviews that are meant to allow individuals to
directly confront the event and share their feelings with the counselor and to help structure their memories of the
event. However, while this form of therapy is the most often used it is actually the least effective.[101] Studies have
had mixed findings concerning psychological debriefings and have ranged from being of significant help to helping
in the formation of PTSD in individuals who would otherwise have not developed PTSD. The greater number of
studies tends to simply find that it is neither overly beneficial nor harmful.
Risk Targeted Interventions
Risk targeted interventions are those that attempt to mitigate specific formative information or events. It can target
modeling normal behaviors, instruction on a task or giving information on the event. For example,[107] rape victims
were given an instruction video on the procedures for a forensic exam. Also included in the video was advice on how
to identify and stop avoidance behavior and control anxiety. Finally, the individuals modeling the forensic exam
were shown to be calm and relaxed. PTSD diagnosis for those who saw the video were thirty three percent less than
for those who went through the standard forensic procedure.
260

Psychobiological Treatments
Psychobiological treatments have also found success, especially with cortisol.[101] Psychobiological treatments target
biological changes that occur after a traumatic event. They also attempt to chemically alter learning or memory
formation. Cortisol treatments after a traumatic event have found success in mitigating later diagnosis of PTSD. As
discussed earlier Cortisol is often lower in individuals who are at risk of PTSD after a traumatic event than their
counterparts. By increasing cortisol levels to normal levels this has been shown to reduce arousal post event as well
prevent GR upregulation.
Stepped Collaborative Care
Stepped collaborative care is where individuals who are at risk are monitored for symptoms.[101] As symptoms of
PTSD appear the level of care is increased to treat those symptoms.
Psychotherapeutic interventions
Many forms of psychotherapy have been advocated for trauma-related problems such as PTSD. Basic counseling
practices common to many treatment responses for PTSD include education about the condition and provision of
safety and support.[108]
The psychotherapy programs with the strongest demonstrated efficacy include cognitive behavioral programs,
variants of exposure therapy, stress inoculation training (SIT), variants of cognitive therapy (CT), eye movement
desensitization and reprocessing (EMDR), and many combinations of these procedures.[109] [110] A 2010 review
disagrees that these treatments have proven efficacy, and points out methodological flaws in the studies and previous
meta-analyses.[111]
EMDR or trauma-focused cognitive behavioral therapy (TFCBT) was recommended as first-line treatments for
trauma victims in a 2007 review; however, "the evidence base [for EMDR] was not as strong as that for TFCBT ...
Furthermore, there was limited evidence that TFCBT and EMDR were superior to supportive/non-directive
treatments, hence it is highly unlikely that their effectiveness is due to non-specific factors such as attention."[112] A
meta-analytic comparison of EMDR and cognitive behavioral therapy found both protocols indistinguishable in
terms of effectiveness in treating PTSD; however "the contribution of the eye movement component in EMDR to
treatment outcome" is unclear.[113]
Behavioral and Cognitive Behavioral therapy
Cognitive behavioral therapy (CBT) seeks to change the way a trauma victim feels and acts by changing the patterns
of thinking and/or behavior responsible for negative emotions. CBT have been proven to be an effective treatment
for PTSD, and is currently considered the standard of care for PTSD by the United States Department of Defense[114]
In CBT, individuals learn to identify thoughts that make them feel afraid or upset, and replace them with less
distressing thoughts. The goal is to understand how certain thoughts about events cause PTSD-related stress.
Recent research on contextually based third-generation behavior therapies suggests that they may produce results
comparable to some of the better validated therapies.[115] Many of these therapy methods have a significant element
of exposure,[116] and have demonstrated success in treating the primary problems of PTSD and co-occurring
depressive symptoms.[117]
Exposure therapy is a type of cognitive behavioral therapy[118] that involves assisting trauma survivors to
re-experience distressing trauma-related memories and reminders in order to facilitate habituation and successful
emotional processing of the trauma memory. Most exposure therapy programs include both imaginal confrontation
with the traumatic memories and real-life exposure to trauma reminders; this therapy modality is well supported by
clinical evidence. Indeed, the success of exposure-based therapies has raised the question of whether exposure is a
necessary ingredient in the treatment of PTSD.[119] Some organizations have endorsed the need for exposure.[120]
[121]
The US Department of Veterans Affairs has been actively training mental health treatment staff in prolonged
261

exposure therapy[122] and Cognitive Processing Therapy[123] in an effort to better treat US Veterans with PTSD.
Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) is specifically targeted as a treatment for PTSD.[124] Based
on the evidence of controlled research, the American Psychiatric Association[125] and the United States Department
of Veterans Affairs and Department of Defense[126] have placed EMDR in the highest category of effectiveness and
research support in the treatment of trauma. Several international bodies have made similar recommendations.[127]
However, some reviewers no longer believe that the eye movements assist in recovery, proposing instead that the
review of and engagement with memories, processing of cognitions, and rehearsal of coping skills are the
psychotherapeutically effective components of the procedure.[111] [128]
Interpersonal psychotherapy
Other approaches, particularly involving social supports,[65] [66] may also be important. An open trial of
interpersonal psychotherapy[129] reported high rates of remission from PTSD symptoms without using exposure.[130]
A current, NIMH-funded trial in New York City is now (and into 2013) comparing interpersonal psychotherapy,
prolonged exposure therapy, and relaxation therapy.[131] [132] [133]
Medication
A variety of medications has shown adjunctive benefit in reducing PTSD symptoms,[134] but "there is no clear drug
treatment for PTSD".[135] Positive symptoms (re-experiencing, hypervigilance, increased arousal) generally respond
better to medication than negative symptoms (avoidance, withdrawal), and it is recommended that any drug trial last
for at least 68 weeks.[135]
Symptom management: potentially useful medication classes
SSRIs (selective serotonin reuptake inhibitors). SSRIs are considered to be a first-line drug treatment.[136] [137]
SSRIs for which there are data to support use include: citalopram, escitalopram,[138] fluoxetine,[139]
fluvoxamine,[140] paroxetine,[141] and sertraline.[139] [142]
Among the anti-depressants described in this section, bupropion and venlafaxine have the lowest patient drop-out
rates. Sertraline, fluoxetine, and nefazodone have a modestly higher drop-out rate (~15%), and the heterocyclics and
paroxetine have the highest rates (~20%+).[143] Where drop-out is caused or feared because of medication
side-effects, it should be remembered that most patients do not experience such side-effects.[144]
Alpha-adrenergic antagonists. Prazosin ("Minipress"), in a small study of combat veterans, has shown substantial
benefit in relieving or reducing nightmares.[145] Clonidine ("Catapres") can be helpful with startle, hyperarousal, and
general autonomic hyperexcitability.[]
Anti-convulsants, mood stabilizers, anti-aggression agents. Carbamazepine ("Tegretol") has likely benefit in
reducing arousal symptoms involving noxious affect,[139] as well as mood or aggression.[146] Topiramate
("Topamax")[145] has been effective in achieving major reductions in flashbacks and nightmares, and no reduction of
effect was seen over time.[145] Zolpidem ("Ambien") has also proven useful in treating sleep disturbances.[147]
Lamotrigine ("Lamictal") may be useful in reducing reexperiencing symptoms, as well as avoidance and emotional
numbing.[] [148] [149] [150] Valproic acid ("Depakene") and has shown reduction of symptoms of irritability,
aggression, and impulsiveness, and in reducing flashbacks.[] Similarly, lithium carbonate has worked to control
mood and aggressions (but not anxiety) symptoms.[146] Buspirone ("BuSpar") has an effect similar to that of lithium,
with the additional benefit of working to reduce hyperarousal symptoms.[]
Antipsychotics. Risperidone can be used to help with dissociation, mood issues, and aggression.[151]
Atypical antidepressants.[152] Nefazodone ("Serzone") can be effective with sleep disturbance symptoms, and with
secondary depression, anxiety, and sexual dysfunction symptoms.[139] Trazodone ("Desyrel") can also reduce or
262

eliminate problems with disturbed sleep, and with anger and anxiety.[139]
Beta blockers. Propranolol ("Inderal") has demonstrated possibilities in reducing hyperarousal symptoms, including
sleep disturbances.[147] [153]
Benzodiazepines. These can be used with caution for short-term anxiety relief,[151] [154] hyperarousal, and sleep
disturbance.[147] While benzodiazepines can alleviate acute anxiety, there is no consistent evidence that they can stop
the development of PTSD, or are at all effective in the treatment of posttraumatic stress disorder. Additionally
benzodiazepines may reduce the effectiveness of psychotherapeutic interventions and there is some evidence that
benzodiazepines may contribute to the development and chronification of PTSD. Other drawbacks include the risk of
developing a benzodiazepine dependence and withdrawal syndrome; additionally individuals with PTSD are at an
increased risk of abusing benzodiazepines.[136] [155]
Glucocorticoids. Additionally, post-stress high dose corticosterone administration was recently found to reduce
'PTSD-like' behaviors in a rat model of PTSD. In this study, corticosterone impaired memory performance,
suggesting that it may reduce risk for PTSD by interfering with consolidation of traumatic memories.[156] The
neurodegenerative effects of the glucocorticoids, however, may prove this treatment counterproductive.[157]
Heterocyclic / Tricyclic anti-depressants anti-depressants. Amitriptyline ("Elavil") has shown benefit for positive
distress symptoms, and for avoidance, and Imipramine ("Tofranil") has shown benefit for intrusive symptoms.[139]
Monoamine-oxidase inhibitors (MAOIs). Phenelzine ("Nardil") has for some time been observed to be effective
with hyperarousal and depression, and is especially effective with nightmares.[139]
Miscellaneous other medications. Clinical trials evaluating methylenedioxymethamphetamine (MDMA, "Ecstasy")
in conjunction with psychotherapy are being conducted in Switzerland[158] and Israel.[159]
Symptom prevention: potentially useful medication classes
Some medications have shown benefit in preventing PTSD or reducing its incidence, when given in close proximity
to a traumatic event. These medications include:
Alpha-adrenergic antagonists. Anecdotal report of success in using clonidine ("Catapres") to reduce traumatic
stress symptoms[160] suggests that it may have benefit in preventing PTSD.
Beta blockers. Propranolol ("Inderal"), similarly to clonidine, may be useful if there are significant symptoms of
"over-arousal". These may inhibit the formation of traumatic memories by blocking adrenaline's effects on the
amygdala.[153]
Glucocorticoids. There is some evidence suggesting that administering glucocorticoids immediately after a
traumatic experience may help prevent PTSD. Several studies have shown that individuals who receive high doses of
hydrocortisone for treatment of septic shock, or following surgery, have a lower incidence and fewer symptoms of
PTSD.[161] [162] [163]
Opiates. In a retrospective analysis of combat injury field data for US troops in Iraq, it was found that those who
received morphine in the early stages of their treatment had a significantly lower rate of subsequent PTSD, when
compared with those who did not receive morphine at that time.[164]
Medications by symptom group affected
Medications can affect one or more of the symptoms, in one or more of the three major symptom classes[8] involved
in diagnosing PTSD, which can be summarized in the following table:[151] [154] [165]
263
Symptom
class
264
Symptom
Medication
Reexperiencing
intrusive recall
amitriptyline; fluoxetine; imipramine; lamotrigine; sertraline
intrusive reexperiencing
amitriptyline; fluoxetine; imipramine; nefazodone; sertraline (women

only); topiramate;
sleep disturbance, nightmares
benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine;

prazosin; topiramate; trazodone; zolpidem
dissociative recall
risperidone
intense psychological distress (anger, anxiety) when

exposed to reminders of traumatic event(s)
benzodiazepines; buspirone; carbamazepine; lithium (not for

anxiety); nefazodone; trazodone
avoidance
amitriptyline; fluoxetine; lamotrigine; nefazodone; sertraline
feelings of detachment or estrangement from others
amitriptyline; risperidone
restricted range of affect (numbing)
amitriptyline; lamotrigine; sertraline (women only)
general hyperarousal
amitriptyline; nefazodone; phenelzine; sertraline (women only)
sleep disturbance, nightmares
benzodiazepines; carbamazepine; clonidine; nefazodone; phenelzine;

trazodone; zolpidem
irritability, anger (and impulsiveness)
carbamazepine; nefazodone; valproic acid
anger
buspirone; fluoxetine; lithium; trazodone
aggression
risperidone
exaggerated startle response; general autonomic

hyperexcitability
benzodiazepines; buspirone; carbamazepine; clonidine; propranolol;

valproic acid
Avoidance
Hyperarousal
Some medications can also help with symptoms which may occur secondary to PTSD.[165]
Secondary symptom
depression
Medication
nefazodone; phenelzine
dream content distortions nefazodone

relapse of symptoms
carbamazepine;
self-mutilation
clonidine; buprenorphine
sexual function reduction nefazodone

sleep hours reduction
nefazodone
265
Medication and self-medication issues and risks with PTSD

Alcohol abuse and drug abuse commonly co-occur with PTSD.[145] Recovery from posttraumatic stress disorder or
other anxiety disorders may be hindered, or the condition worsened, by medication or substance overuse, abuse, or
dependence; resolving these problems can bring about a marked improvement in an individual's mental health status
and anxiety levels.[166] [167]
Benzodiazepines are risky in several ways. They can be especially addictive when PTSD is present, and this is
especially true with the fast-acting ones. Dis-inhibition upon initiation of treatment is another risk with this
medication class. Finally, termination of the drug can be especially difficult.[145] Recovery from benzodiazepine
abuse or dependence tends to take a lot longer than recovery from alcohol abuse or dependence, but people can
regain their previous good health. PTSD symptoms may temporarily worsen however, during alcohol withdrawal or
benzodiazepine withdrawal.[166]
Yohimbine (not considered specifically appropriate for PTSD) increases arousal by increasing release of
endogenous norepinephrine, and can worsen PTSD symptoms.[145]
Epidemiology
There is debate over the rates of
PTSD found in populations, but
despite changes in diagnosis and
the criteria used to define PTSD
between
1997
and
2007,
epidemiological rates have not
changed significantly.[10]
International PTSD rates
Disability-adjusted life year rates for post-traumatic stress disorder per 100,000inhabitants in
2004. "Mortality and Burden of Disease Estimates for WHO Member States in 2004". World
Health Organization. .no data<
43.543.5-4545-46.546.5-4848-49.549.5-5151-52.552.5-5454-55.555.5-5757-58.5>
58.5
The United Nations' World Health

Organization publishes estimates of PTSD impact for each of its member states; the latest data available are for
2004. Considering only the 25 most populated countries,[169] ranked by overall age-standardized Disability-Adjusted
Life Year (DALY) rate, the top half of the ranked list is dominated by Asian/Pacific countries, the USA, and
Egypt.[170] Ranking the countries by the male-only or female-only rates produces much the same result, but with less
meaningfulness, as the score range in the single sex rankings is much reduced (4 for women, 3 for men, as compared
with 14 for the overall score range), suggesting that the differences between female and male rates, within each
country, is what drives the distinctions between the countries.[171] [172]
Age-standardized Disability-adjusted life year (DALY) rates for PTSD, per 100,000
inhabitants, in 25 most populous countries,[169] ranked by overall rate (2004)
Region
Country
PTSD DALY
rate,
overall
[170]
PTSD DALY
rate,
females
[171]
PTSD DALY
rate,
[172]
males
Asia / Pacific Thailand
59
86
30
Asia / Pacific Indonesia
58
86
30
Asia / Pacific Philippines
58
86
30
Americas
58
86
30
57
85
29
USA
Asia / Pacific Bangladesh
Africa
266
Egypt
56
83
30
Asia / Pacific India
56
85
29
Asia / Pacific Iran
56
83
30
Asia / Pacific Pakistan
56
85
29
Asia / Pacific Japan
55
80
31
Asia / Pacific Myanmar
55
81
30
Europe
55
81
30
Asia / Pacific Vietnam
55
80
30
Europe
France
54
80
28
Europe
Germany
54
80
28
Europe
Italy
54
80
28
Asia / Pacific Russian Federation
54
78
30
Europe
United Kingdom
54
80
28
Africa
Nigeria
53
76
29
Africa
Dem. Republ. of Congo 52
76
28
Africa
Ethiopia
52
76
28
Africa
South Africa
52
76
28
Asia / Pacific China
51
76
28
Americas
Mexico
46
60
30
Americas
Brazil
45
60
30
Turkey
United States
The National Comorbidity Survey [173] has estimated that the lifetime prevalence of PTSD among adult Americans is
7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives.[55]
The United States Department of Veterans Affairs estimates that 830,000 Vietnam War veterans suffered symptoms
of PTSD.[174] The National Vietnam Veterans' Readjustment Study (NVVRS) found 15.2% of male and 8.5% of
female Vietnam Vets to suffer from current PTSD at the time of the study. Life-Time prevalence of PTSD was
30.9% for males and 26.9% for females. In a reanalysis of the NVVRS data, along with analysis of the data from the
Matsunaga Vietnam Veterans Project, Schnurr, Lunney, Sengupta, and Waelde found that, contrary to the initial
analysis of the NVVRS data, a large majority of Vietnam veterans suffered from PTSD symptoms (but not the
disorder itself). Four out of five reported recent symptoms when interviewed 2025 years after Vietnam.[64]
In other species
There have been reports of captive[175] and wild[176] elephants suffering from posttraumatic stress reactions, the
latter from seeing members of their herd shot by hunters. Service dogs used overseas in the military have been
said[177] to develop posttraumatic stress after witnessing war.
History
Earliest reports
Reports of battle-associated stress reactions appear as early as the 6th century BC/BCE.[178] One of the first
descriptions of PTSD was made by the Greek historian Herodotus. In 490 BC/BCE he described, during the Battle of
Marathon, an Athenian soldier who suffered no injury from war but became permanently blind after witnessing the
death of a fellow soldier.[179]
Modern recognition in military settings

In the early 19th century military medical doctors
started diagnosing soldiers with "exhaustion" after the
stress of battle. This "exhaustion" was characterized by
mental shutdown due to individual or group trauma.
Soldiers during the 19th century were not supposed to
be scared or show any fear in the midst of battle. The
only treatment for this "exhaustion" was to bring the
afflicted to the back for a bit then send them back into
battle. During the intense and frequently repeated
stress, the soldiers became fatigued as a part of their
body's natural shock reaction.[180]
According to Stphane Audoin-Rouzeau and Annette
Becker, "One-tenth of mobilized American men were
Statue, Three Servicemen, Vietnam Veterans Memorial
hospitalized for mental disturbances between 1942 and
1945, and after thirty-five days of uninterrupted
combat, 98% of them manifested psychiatric disturbances in varying degrees."[181]
Although PTSD-like symptoms have also been recognized in combat veterans of many military conflicts since, the
modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being
experienced by US military veterans of the war in Vietnam.[178]
Previous diagnoses now considered historical equivalents of PTSD include railway spine, stress syndrome, shell
shock, battle fatigue, or traumatic war neurosis.
267
Terminology
The term post-traumatic stress disorder (PTSD) was coined in the mid 1970s,[178] in part through the efforts of
anti-Vietnam War activists and the anti war group Vietnam Veterans Against the War and Chaim F. Shatan, who
worked with them and coined the term post-Vietnam Syndrome; the condition was added to the DSM-III as
posttraumatic stress disorder.[182]
Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders.[182]
The term was formally recognized in 1980.[178] (In the DSM-IV, the spelling "posttraumatic stress disorder" is used,
while in the ICD-10 the spelling is "post-traumatic...".[183] Elsewhere, especially in less formal writing, the term may
be rendered as two words "post traumatic stress disorder".)
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External links
Posttraumatic stress disorder (http://www.dmoz.org/Health/Mental_Health/Disorders/Anxiety/
Post-traumatic_Stress/) at the Open Directory Project
PTSD professional associations (http://www.dmoz.org/Health/Mental_Health/Disorders/Anxiety/
Post-traumatic_Stress/Associations/) at the Open Directory Project
Management of PTSD in adults and children (http://www.nice.org.uk/guidance/index.jsp?action=byID&
o=10966) by the National Institute for Health and Clinical Excellence (UK)
Practice guidelines (http://www.psychiatryonline.com/pracGuide/pracGuideTopic_11.aspx) from the
American Psychiatric Association
Post Traumatic Stress Disorder Information Resource (http://www.som.uq.edu.au/ptsd) from The University
of Queensland School of Medicine (http://www2.som.uq.edu.au/som/Pages/default.aspx)
Resources for Parents of Children with PTSD (http://www.aftertheinjury.org/) from The Children's Hospital of
Philadelphia (http://www.chop.edu/)
275
276

Children need sensitive and responsive caregivers to develop secure attachments. RAD arises from a failure to form normal attachments to primary
caregivers in early childhood.
[1]
ICD-10
F94.1
ICD-9
313.89
eMedicine
ped/2646
MeSH
D019962
, F94.2
[2]
[3]
[4]
Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon
disorder that can affect children.[5] [6] RAD is characterized by markedly disturbed and developmentally
inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or
respond to most social interactions in a developmentally appropriate wayknown as the "inhibited" formor can
present itself as indiscriminate sociability, such as excessive familiarity with relative strangersknown as the
"disinhibited form". The term is used in both the World Health Organization's International Statistical Classification
of Diseases and Related Health Problems (ICD-10)[7] and in the DSM-IV-TR, the revised fourth edition of the
American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).[8] In ICD-10, the
inhibited form is called RAD, and the disinhibited form is called "disinhibited attachment disorder", or "DAD". In
the DSM, both forms are called RAD; for ease of reference, this article will follow that convention and refer to both
forms as reactive attachment disorder.
RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could
result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six
months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's
communicative efforts. Not all, or even a majority of such experiences, result in the disorder.[9] It is differentiated
from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as
mental retardation, all of which can affect attachment behavior. The criteria for a diagnosis of a reactive attachment
disorder are very different from the criteria used in assessment or categorization of attachment styles such as
insecure or disorganized attachment.
Children with RAD are presumed to have grossly disturbed internal working models of relationships which may lead
to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack

of clarity about the presentation of the disorder beyond the age of five years.[10] [11] However, the opening of
orphanages in Eastern Europe following the end of the Cold War in the early-1990s provided opportunities for
research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding
of the prevalence, causes, mechanism and assessment of disorders of attachment and led to efforts from the
late-1990s onwards to develop treatment and prevention programs and better methods of assessment. Mainstream
theorists in the field have proposed that a broader range of conditions arising from problems with attachment should
be defined beyond current classifications.[12]
Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors
are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or
if that is not possible, placing the child with a different caregiver.[13] Most such strategies are in the process of being
evaluated. Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment
of alleged reactive attachment disorder or attachment disorder within the complementary and alternative medicine
field commonly known as attachment therapy. Attachment therapy has an unconventional theoretical base and uses
diagnostic criteria or symptom lists unrelated to criteria under ICD-10 or DSM-IV-TR, or to attachment behaviors. A
range of treatment approaches are used in attachment therapy, some of which are physically coercive and considered
to be antithetical to attachment theory.[14]
Signs and symptoms

Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the
disorder. The initial presentation varies according to the child's developmental and chronological age, although it
always involves a disturbance in social interaction. Infants up to about 1824 months may present with non-organic
failure to thrive and display abnormal responsiveness to stimuli. Laboratory investigations will be unremarkable
barring possible findings consistent with malnutrition or dehydration, while serum growth hormone levels will be
normal or elevated.[15]
The core feature is severely inappropriate social relating by affected children. This can manifest itself in two ways:
1. Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative
strangers (older children and adolescents may also aim attempts at peers)
2. Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when
distressed[16]
While RAD is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone
cannot be made, as children can form stable attachments and social relationships despite marked abuse and
neglect.[17]
Assessment tools
There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of
measures is used in research and diagnosis. Recognized assessment methods of attachment styles, difficulties or
disorders include the Strange Situation Procedure (devised by developmental psychologist Mary Ainsworth),[18] [19]
[20]
the separation and reunion procedure and the Preschool Assessment of Attachment,[21] the Observational Record
of the Caregiving Environment,[22] the Attachment Q-sort[23] and a variety of narrative techniques using stem stories,
puppets or pictures. For older children, actual interviews such as the Child Attachment Interview and the
Autobiographical Emotional Events Dialogue can be used. Caregivers may also be assessed using procedures such as
the Working Model of the Child Interview.[24]
More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah
(1999).[25] The DAI is a semi-structured interview designed to be administered by clinicians to caregivers. It covers
12 items, namely "having a discriminated, preferred adult", "seeking comfort when distressed", "responding to
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comfort when offered", "social and emotional reciprocity", "emotional regulation", "checking back after venturing
away from the care giver", "reticence with unfamiliar adults", "willingness to go off with relative strangers",
"self-endangering behavior", "excessive clinging", "vigilance/hypercompliance" and "role reversal". This method is
designed to pick up not only RAD but also the proposed new alternative categories of disorders of attachment.
Causes
Although increasing numbers of childhood mental health problems are being attributed to genetic defects,[26]
reactive attachment disorder is by definition based on a problematic history of care and social relationships. Abuse
can occur alongside the required factors, but on its own does not explain attachment disorder.[27] It has been
suggested that types of temperament, or constitutional response to the environment, may make some individuals
susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years.[28] In the absence
of available and responsive caregivers it appears that some children are particularly vulnerable to developing
attachment disorders.[29]
There is as yet no explanation for why similar abnormal parenting may produce the two distinct forms of the
disorder, inhibited and disinhibited. The issue of temperament and its influence on the development of attachment
disorders has yet to be resolved. RAD has never been reported in the absence of serious environmental adversity yet
outcomes for children raised in the same environment vary widely.[30]
In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study, it has been
suggested that the roots of various forms of psychopathology, including RAD, Borderline Personality Disorder
(BPD), and post-traumatic stress disorder (PTSD), can be found in disturbances in affect regulation. The subsequent
development of higher-order self-regulation is jeopardized and the formation of internal models is affected.
Consequently the "templates" in the mind that drive organized behavior in relationships may be impacted. The
potential for re-regulation (modulation of emotional responses to within the normal range) in the presence of
corrective experiences (normative caregiving) seems possible. Like many other papers in this poorly-researched
area many new avenues of enquiry are raised.[31]
Diagnosis
RAD is one of the least researched and most poorly understood disorders in the DSM. There is little systematic
epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose
accurately.[16] There is a lack of clarity about the presentation of attachment disorders over the age of five years and
difficulty in distinguishing between aspects of attachment disorders, disorganized attachment or the consequences of
maltreatment.[11]
According to the American Academy of Child and Adolescent Psychiatry (AACAP), children who exhibit signs of
reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan. The
signs or symptoms of RAD may also be found in other psychiatric disorders and AACAP advises against giving a
child this label or diagnosis without a comprehensive evaluation.[10] Their practice parameter states that the
assessment of reactive attachment disorder requires evidence directly obtained from serial observations of the child
interacting with his or her primary caregivers and history (as available) of the childs patterns of attachment behavior
with these caregivers. In addition it requires observations of the childs behavior with unfamiliar adults and a
comprehensive history of the childs early caregiving environment including, for example, pediatricians, teachers, or
caseworkers.[10] In the US, initial evaluations may be conducted by psychologists, psychiatrists, specialist Licensed
Clinical Social Workers or psychiatric nurses.[32]
In the UK, the British Association for Adoption and Fostering (BAAF), advise that only a psychiatrist can diagnose
an attachment disorder and that any assessment must include a comprehensive evaluation of the childs individual
and family history.[33]
278

According to the AACAP Practice Parameter (2005) the question of whether attachment disorders can reliably be
diagnosed in older children and adults has not been resolved. Attachment behaviors used for the diagnosis of RAD
change markedly with development and defining analogous behaviors in older children is difficult. There are no
substantially validated measures of attachment in middle childhood or early adolescence.[10] Assessments of RAD
past school age may not be possible at all as by this time children have developed along individual lines to such an
extent that early attachment experiences are only one factor among many that determine emotion and behavior.[34]
Criteria
ICD-10 describes reactive attachment disorder of childhood, known as RAD, and disinhibited attachment disorder,
less well known as DAD. DSM-IV-TR also describes reactive attachment disorder of infancy or early childhood
divided into two subtypes, inhibited type and disinhibited type, both known as RAD. The two classifications are
similar, and both include:
markedly disturbed and developmentally inappropriate social relatedness in most contexts;
the disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive
developmental disorder;
onset before five years of age;
a history of significant neglect;
an implicit lack of identifiable, preferred attachment figure.
ICD-10 states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe
parental neglect, abuse, or serious mishandling. DSM states in relation to both forms there must be a history of
"pathogenic care" defined as persistent disregard of the child's basic emotional or physical needs or repeated changes
in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to
account for the disorder. For this reason, part of the diagnosis is the child's history of care rather than observation of
symptoms.
In DSM-IV-TR the inhibited form is described as: Persistent failure to initiate or respond in a developmentally
appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly
ambivalent and contradictory responses (e.g. the child may respond to caregivers with a mixture of approach,
avoidance, and resistance to comforting, or may exhibit "frozen watchfulness", hypervigilance while keeping an
impassive and still demeanour).[8] Such infants do not seek and accept comfort at times of threat, alarm or distress,
thus failing to maintain "proximity", an essential element of attachment behavior. The disinhibited form shows:
Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective
attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment
figures).[8] There is therefore a lack of "specificity" of attachment figure, the second basic element of attachment
behavior.
The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included
in DSM-IV-TR as follows:
abuse, (psychological or physical), in addition to neglect;
associated emotional disturbance;
poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases,
(inhibited form only);
evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness
in interactions with appropriately responsive, non-deviant adults, (disinhibited form only).
The first of these is somewhat controversial, being a commission rather than omission and because abuse of itself
does not lead to attachment disorder.
The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is
more enduring.[35] ICD-10 states the disinhibited form "tends to persist despite marked changes in environmental
279

circumstances". Disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the
same child.[36] The question of whether there are in fact two subtypes has been raised. The World Health
Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate
subdivision.[7] One reviewer has commented on the difficulty of clarifying the core characteristics of and differences
between atypical attachment styles and various ways of categorizing more severe disorders of attachment.[37]
As of 2010, the proposal for DSM-V is to replace the division of RAD into inhibited and disinhibited types with two
disorders, one called Reactive Attachment Disorder of Infancy and Early Childhood, corresponding to the inhibited
type, and the other called Disinhibited Social Engagement Disorder, corresponding to the disinhibited type.[38]
Differential diagnosis
The diagnostic complexities of RAD mean that careful diagnostic evaluation by a trained mental health expert with
particular expertise in differential diagnosis is considered essential.[39] [40] [41] Several other disorders, such as
conduct disorders, oppositional defiant disorder, anxiety disorders, post traumatic stress disorder and social phobia
share many symptoms and are often comorbid with or confused with RAD, leading to over and under diagnosis.
RAD can also be confused with neuropsychiatric disorders such as autism spectrum disorders, pervasive
developmental disorder, childhood schizophrenia and some genetic syndromes. Infants with this disorder can be
distinguished from those with organic illness by their rapid physical improvement after hospitalization.[15] Children
with an autistic disorder are likely to be of normal size and weight and often exhibit a degree of mental retardation.
They are unlikely to improve upon being removed from the home.[15] [39] [40] [41]
Alternative diagnosis
In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists,
outside the DSM and ICD, were created out of clinical and parental experience within the field known as attachment
therapy. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by
unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such
as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either
DSM-IV-TR or ICD-10.[42] Many children are being diagnosed with RAD because of behavioral problems that are
outside the criteria.[39] There is an emphasis within attachment therapy on aggressive behavior as a symptom of what
they describe as attachment disorder whereas mainstream theorists view these behaviors as comorbid, externalizing
behaviors requiring appropriate assessment and treatment rather than attachment disorders. However, knowledge of
attachment relationships can contribute to the etiology, maintenance and treatment of externalizing disorders.[43]
The Randolph Attachment Disorder Questionnaire or RADQ is one of the better known of these checklists and is
used by attachment therapists and others.[44] The checklist includes 93 discrete behaviours, many of which either
overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment
difficulties. Critics assert that it is unvalidated[45] and lacks specificity.[46]
Treatment
Assessing the child's safety is an essential first step that determines whether future intervention can take place in the
family unit or whether the child should be removed to a safe situation. Interventions may include psychosocial
support services for the family unit (including financial or domestic aid, housing and social work support),
psychotherapeutic interventions (including treating parents for mental illness, family therapy, individual therapy),
education (including training in basic parenting skills and child development), and monitoring of the child's safety
within the family environment[15]
In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W. Boris
and C.H. Zeanah) based on its published parameters for the diagnosis and treatment of RAD.[10] Recommendations
in the guidelines include the following:
280

1. "The most important intervention for young children diagnosed with reactive attachment disorder and who lack
an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an
emotionally available attachment figure."
2. "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing
the caregiver's attitudes toward and perceptions about the child is important for treatment selection."
3. "Children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to
others. After ensuring that the child is in a safe and stable placement, effective attachment treatment must focus
on creating positive interactions with caregivers."
4. "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional
behavior require adjunctive (additional) treatments."
Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and
younger children are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of
the caregiver, or if that is not possible, placing the child with a different caregiver.[10] [47] [48] These approaches are
mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment
status or caregiving responses of the adult caregiver as attachment is a two-way process involving attachment
behavior and caregiver response. Some of these treatment or prevention programs are specifically aimed at foster
carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often do not
elicit appropriate caregiver responses.[49] Approaches include "Watch, wait and wonder",[50] manipulation of
sensitive responsiveness,[51] [52] modified "Interaction Guidance",[53] "Clinician-Assisted Videofeedback Exposure
Sessions (CAVES)",[54] "Preschool Parent Psychotherapy",[55] "Circle of Security",[56] [57] "Attachment and
Biobehavioral Catch-up" (ABC),[58] the New Orleans Intervention,[59] [60] [61] and Parent-Child psychotherapy.[62]
Other treatment methods include Developmental, Individual-difference, and Relationship-based therapy (DIR, also
referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive
developmental disorders.[63]
The relevance of these approaches to intervention with fostered and adopted children with RAD or older children
with significant histories of maltreatment is unclear.[64]
Alternative treatment
Outside the mainstream programs is a form of treatment generally known as attachment therapy, a subset of
techniques (and accompanying diagnosis) for supposed attachment disorders including RAD. In general, these
therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new
caregivers. The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting
methods which emphasize obedience and parental control.[65] There is considerable criticism of this form of
treatment and diagnosis as it is largely unvalidated and has developed outside the scientific mainstream.[66] There is
little or no evidence base and techniques vary from non-coercive therapeutic work to more extreme forms of
physical, confrontational and coercive techniques, of which the best known are holding therapy, rebirthing,
rage-reduction and the Evergreen model. These forms of the therapy may well involve physical restraint, the
deliberate provocation of rage and anger in the child by physical and verbal means including deep tissue massage,
aversive tickling, enforced eye contact and verbal confrontation, and being pushed to revisit earlier trauma.[67] [68]
Critics maintain that these therapies are not within the attachment paradigm, are potentially abusive,[69] and are
antithetical to attachment theory.[14] The APSAC Taskforce Report of 2006 notes that many of these therapies
concentrate on changing the child rather than the caregiver.[70] Children may be described as "RADs", "Radkids" or
"Radishes" and dire predictions may be made as to their supposedly violent futures if they are not treated with
attachment therapy.[65]
281
Prognosis
The AACAP guidelines state that children with reactive attachment disorder are presumed to have grossly disturbed
internal models for relating to others.[10] However, the course of RAD is not well studied and there have been few
efforts to examine symptom patterns over time. The few existing longitudinal studies (dealing with developmental
change with age over a period of time) involve only children from poorly run Eastern European institutions.[10]
Findings from the studies of children from Eastern European orphanages indicate that persistence of the inhibited
pattern of RAD is rare in children adopted out of institutions into normative care-giving environments. However,
there is a close association between duration of deprivation and severity of attachment disorder behaviors.[71] The
quality of attachments that these children form with subsequent care-givers may be compromised, but they probably
no longer meet criteria for inhibited RAD.[72] The same group of studies suggests that a minority of adopted,
institutionalized children exhibit persistent indiscriminate sociability even after more normative caregiving
environments are provided.[31] Indiscriminate sociability may persist for years, even among children who
subsequently exhibit preferred attachment to their new caregivers. Some exhibit hyperactivity and attention problems
as well as difficulties in peer relationships.[73] In the only longitudinal study that has followed children with
indiscriminate behavior into adolescence, these children were significantly more likely to exhibit poor peer
relationships.[74]
Studies of children who were reared in institutions have suggested that they are inattentive and overactive, no matter
what quality of care they received. In one investigation, some institution-reared boys were reported to be inattentive,
overactive, and markedly unselective in their social relationships, while girls, foster-reared children, and some
institution-reared children were not. It is not yet clear whether these behaviors should be considered as part of
disordered attachment.[75]
There is one case study on maltreated twins published in 1999 with a follow-up in 2006. This study assessed the
twins between the ages of 19 and 36 months, during which time they suffered multiple moves and placements.[76]
The paper explores the similarities, differences and comorbidity of RAD, disorganized attachment and post traumatic
stress disorder. The girl showed signs of the inhibited form of RAD while the boy showed signs of the indiscriminate
form. It was noted that the diagnosis of RAD ameliorated with better care but symptoms of post traumatic stress
disorder and signs of disorganized attachment came and went as the infants progressed through multiple placement
changes. At age three, some lasting relationship disturbance was evident.
In the follow-up case study when the twins were aged three and eight years, the lack of longitudinal research on
maltreated as opposed to institutionalized children was again highlighted. The girl's symptoms of disorganized
attachment had developed into controlling behaviorsa well-documented outcome. The boy still exhibited
self-endangering behaviors, not within RAD criteria but possibly within "secure base distortion", (where the child
has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while
gradually exploring the environment). At age eight the children were assessed with a variety of measures including
those designed to access representational systems, or the child's "internal working models". The twins' symptoms
were indicative of different trajectories. The girl showed externalizing symptoms (particularly deceit), contradictory
reports of current functioning, chaotic personal narratives, struggles with friendships, and emotional disengagement
with her caregiver, resulting in a clinical picture described as "quite concerning". The boy still evidenced
self-endangering behaviors as well as avoidance in relationships and emotional expression, separation anxiety and
impulsivity and attention difficulties. It was apparent that life stressors had impacted each child differently. The
narrative measures used were considered helpful in tracking how early attachment disruption is associated with later
expectations about relationships.[31]
One paper using questionnaires found that children aged three to six, diagnosed with RAD, scored lower on empathy
but higher on self-monitoring (regulating your behavior to "look good"). These differences were especially
pronounced based on ratings by parents, and suggested that children with RAD may systematically report their
personality traits in overly positive ways. Their scores also indicated considerably more behavioral problems than
282

scores of the control children.[77]
Epidemiology
Epidemiological data are limited, but reactive attachment disorder appears to be very uncommon.[5] The prevalence
of RAD is unclear but it is probably quite rare, other than in populations of children being reared in the most
extreme, deprived settings such as some orphanages.[29] There is little systematically gathered epidemiologic
information on RAD.[39] A cohort study of 211 Copenhagen children to the age of 18 months found a prevalence of
0.9%.[78]
Attachment disorders tend to occur in a definable set of contexts such as within some types of institutions, in the
presence of repeated changes of primary caregiver or of extremely neglectful identifiable primary caregivers who
show persistent disregard for the child's basic attachment needs, but not all children raised in these conditions
develop an attachment disorder.[79] Studies undertaken on children from Eastern European orphanages from the
mid-1990s showed significantly higher levels of both forms of RAD and of insecure patterns of attachment in the
institutionalized children, regardless of how long they had been there.[80] [] [81] It would appear that children in
institutions like these are unable to form selective attachments to their caregivers. The difference between the
institutionalized children and the control group had lessened in the follow-up study three years later, although the
institutionalized children continued to show significantly higher levels of indiscriminate friendliness.[80] [82]
However, even among children raised in the most deprived institutional conditions the majority did not show
symptoms of this disorder.[71]
A 2002 study of children in residential nurseries in Bucharest, in which the DAI was used, challenged the current
DSM and ICD conceptualizations of disordered attachment and showed that inhibited and disinhibited disorders
could coexist in the same child.[83]
There are two studies on the incidence of RAD relating to high risk and maltreated children in the U.S. Both used
ICD, DSM and the DAI. The first, in 2004, reported that children from the maltreatment sample were significantly
more likely to meet criteria for one or more attachment disorders than children from the other groups, however this
was mainly the proposed new classification of disrupted attachment disorder rather than the DSM or ICD classified
RAD or DAD.[84] The second study, also in 2004, attempted to ascertain the prevalence of RAD and whether it
could be reliably identified in maltreated rather than neglected toddlers. Of the 94 maltreated toddlers in foster care,
35% were identified as having ICD RAD and 22% as having ICD DAD, and 38% fulfilled the DSM criteria for
RAD.[36] This study found that RAD could be reliably identified and also that the inhibited and disinhibited forms
were not independent. However, there are some methodological concerns with this study. A number of the children
identified as fulfilling the criteria for RAD did in fact have a preferred attachment figure.[85]
It has been suggested by some within the field of attachment therapy that RAD may be quite prevalent because
severe child maltreatment, which is known to increase risk for RAD, is prevalent and because children who are
severely abused may exhibit behaviors similar to RAD behaviors.[41] The APSAC Taskforce consider this inference
to be flawed and questionable.[41] Severely abused children may exhibit similar behaviors to RAD behaviors but
there are several far more common and demonstrably treatable diagnoses which may better account for these
difficulties.[86] Further, many children experience severe maltreatment and do not develop clinical disorders.[86]
Resilience is a common and normal human characteristic.[87] RAD does not underlie all or even most of the
behavioral and emotional problems seen in foster children, adoptive children, or children who are maltreated and
rates of child abuse and/or neglect or problem behaviors are not a benchmark for estimates of RAD.[41]
There are few data on comorbid conditions, but there are some conditions that arise in the same circumstances in
which RAD arises, such as institutionalization or maltreatment. These are principally developmental delays and
language disorders associated with neglect.[10] Conduct disorders, oppositional defiant disorder, anxiety disorders,
post-traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with
RAD.[41] [76] Attachment disorder behaviors amongst institutionalized children are correlated with attentional and
283

conduct problems and cognitive levels but nonetheless appear to index a distinct set of symptoms and behaviors.[71]
History
Reactive attachment disorder first made its appearance in standard nosologies of psychological disorders in DSM-III,
1980, following an accumulation of evidence on institutionalized children. The criteria included a requirement of
onset before the age of 8 months and was equated with failure to thrive. Both these features were dropped in
DSM-III-R, 1987. Instead, onset was changed to being within the first 5 years of life and the disorder itself was
divided into two subcategories, inhibited and disinhibited. These changes resulted from further research on
maltreated and institutionalized children and remain in the current version, DSM-IV, 1994, and its 2000 text
revision, DSM-IV-TR, as well as in ICD-10, 1992. Both nosologies focus on young children who are not merely at
increased risk for subsequent disorders but are already exhibiting clinical disturbance.[88]
The broad theoretical framework for current versions of RAD is attachment theory, based on work conducted from
the 1940s to the 1980s by John Bowlby, Mary Ainsworth and Ren Spitz. Attachment theory is a framework that
employs psychological, ethological and evolutionary concepts to explain social behaviors typical of young children.
Attachment theory focuses on the tendency of infants or children to seek proximity to a particular attachment figure
(familiar caregiver), in situations of alarm or distress, behavior which appears to have survival value.[89] This is
known as a discriminatory or selective attachment. Subsequently, the child begins to use the caregiver as a base of
security from which to explore the environment, returning periodically to the familiar person. Attachment is not the
same as love and/or affection although they are often associated. Attachment and attachment behaviors tend to
develop between the ages of six months and three years. Infants become attached to adults who are sensitive and
responsive in social interactions with the infant, and who remain as consistent caregivers for some time.[90]
Caregiver responses lead to the development of patterns of attachment, that in turn lead to internal working models
which will guide the individual's feelings, thoughts, and expectations in later relationships.[91] [92] For a diagnosis of
reactive attachment disorder, the child's history and atypical social behavior must suggest the absence of formation
of a discriminatory or selective attachment.
The pathological absence of a discriminatory or selective attachment needs to be differentiated from the existence of
attachments with either typical or somewhat atypical behavior patterns, known as styles or patterns. There are four
attachment styles ascertained and used within developmental attachment research. These are known as secure,
anxious-ambivalent, anxious-avoidant, (all organized)[18] and disorganized.[19] [20] The latter three are characterised
as insecure. These are assessed using the Strange Situation Procedure, designed to assess the quality of attachments
rather than whether an attachment exists at all.[10]
A securely attached toddler will explore freely while the caregiver is present, engage with strangers, be visibly upset
when the caregiver departs, and happy to see the caregiver return. The anxious-ambivalent toddler is anxious of
exploration, extremely distressed when the caregiver departs but ambivalent when the caregiver returns. The
anxious-avoidant toddler will not explore much, avoid or ignore the parentshowing little emotion when the parent
departs or returnsand treat strangers much the same as caregivers with little emotional range shown. The
disorganized/disoriented toddler shows a lack of a coherent style or pattern for coping. Evidence suggests this occurs
when the caregiving figure is also an object of fear, thus putting the child in an irresolvable situation regarding
approach and avoidance. On reunion with the caregiver, these children can look dazed or frightened, freezing in
place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors implying
fear of the person who is being sought. It is thought to represent a breakdown of an inchoate attachment strategy and
it appears to affect the capacity to regulate emotions.[93]
Although there are a wide range of attachment difficulties within the styles which may result in emotional
disturbance and increase the risk of later psychopathologies, particularly the disorganized style, none of the styles
constitute a disorder in themselves and none equate to criteria for RAD as such.[94] A disorder in the clinical sense is
a condition requiring treatment, as opposed to risk factors for subsequent disorders.[10] Reactive attachment disorder
284

denotes a lack of typical attachment behaviors rather than an attachment style, however problematic that style may
be, in that there is an unusual lack of discrimination between familiar and unfamiliar people in both forms of the
disorder. Such discrimination does exist as a feature of the social behavior of children with atypical attachment
styles. Both DSM-IV and ICD-10 depict the disorder in terms of socially aberrant behavior in general rather than
focusing more specifically on attachment behaviors as such. DSM-IV emphasizes a failure to initiate or respond to
social interactions across a range of relationships and ICD-10 similarly focuses on contradictory or ambivalent social
responses that extend across social situations.[88] The relationship between patterns of attachment in the Strange
Situation and RAD is not yet clear.[95]
There is a lack of consensus about the precise meaning of the term "attachment disorder".[96] The term is frequently
used both as an alternative to reactive attachment disorder and in discussions about different proposed classifications
for disorders of attachment beyond the limitations of the ICD and DSM classifications.[88] It is also used within the
field of attachment therapy, as is the term reactive attachment disorder, to describe a range of problematic behaviors
not within the ICD or DSM criteria or not related directly to attachment styles or difficulties at all.[97]
Research
Research from the late 1990s indicated there were disorders of attachment not captured by DSM or ICD and showed
that RAD could be diagnosed reliably without evidence of pathogenic care, thus illustrating some of the conceptual
difficulties with the rigid structure of the current definition of RAD.[98] Research published in 2004 showed that the
disinhibited form can endure alongside structured attachment behavior (of any style) towards the child's permanent
caregivers.[36]
Some authors have proposed a broader continuum of definitions of attachment disorders ranging from RAD through
various attachment difficulties to the more problematic attachment styles. There is as yet no consensus, on this issue
but a new set of practice parameters containing three categories of attachment disorder has been proposed by C.H.
Zeanah and N. Boris. The first of these is disorder of attachment, in which a young child has no preferred adult
caregiver. The proposed category of disordered attachment is parallel to RAD in its inhibited and disinhibited forms,
as defined in DSM and ICD. The second category is secure base distortion, where the child has a preferred familiar
caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the
environment. Such children may endanger themselves, cling to the adult, be excessively compliant, or show role
reversals in which they care for or punish the adult. The third type is disrupted attachment. Disrupted attachment is
not covered under ICD-10 and DSM criteria, and results from an abrupt separation or loss of a familiar caregiver to
whom attachment has developed.[99] This form of categorisation may demonstrate more clinical accuracy overall
than the current DSM-IV-TR classification, but further research is required.[12] [100] The practice parameters would
also provide the framework for a diagnostic protocol. Most recently, Daniel Schechter and Erica Willheim have
shown a relationship between maternal violence-related posttraumatic stress disorder and secure base distortion (see
above) which is characterized by child recklessness, separation anxiety, hypervigilance, and role-reversal.[101]
Some research indicates there may be a significant overlap between behaviors of the inhibited form of RAD or DAD
and aspects of disorganized attachment where there is an identified attachment figure.[93]
An ongoing question is whether RAD should be thought of as a disorder of the child's personality or a distortion of
the relationship between the child and a specific other person. It has been noted that as attachment disorders are by
their very nature relational disorders, they do not fit comfortably into noslogies that characterize the disorder as
centered on the person.[102] Work by C.H. Zeanah[36] indicates that atypical attachment-related behaviors may occur
with one caregiver but not with another. This is similar to the situation reported for attachment styles, in which a
particular parent's frightened expression has been considered as possibly responsible for disorganized/disoriented
reunion behavior during the Strange Situation Procedure.[103]
The draft of the proposed DSM-V suggests dividing RAD into two disorders, Reactive Attachment Disorder for the
current inhibited form of RAD, and Disinhibited Social Engagement Disorder for what is currently the disinhibited
285
286
form of RAD, with some alterations in the proposed DSM definition.[104]
Notes
[1]
[2]
[3]
[4]
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[90] Bowlby [1969] (1997 edition) pp. 31317.
[91] Bretherton I, Munholland KA (1999). "Internal Working Models in Attachment Relationships: A Construct Revisited". In Cassidy J and
Shaver PR (Eds.) Handbook of Attachment: Theory, Research and Clinical Applications. pp. 89111. Guilford Press ISBN 1-57230-087-6.
[92] Bowlby [1969] (1997 edition) p. 354.
[93] Van Ijzendoorn M, Bakermans-Kranenburg M (September 2003). "Attachment disorders and disorganized attachment: Similar and
different". Attachment & Human Development 5 (3): 31320(8). doi:10.1080/14616730310001593938. PMID12944229.
[94] Thompson RA (2000). "The legacy of early attachments". Child Dev 71 (1): 14552. doi:10.1111/1467-8624.00128. PMID10836568.
[95] OConnor TG (2002), "Attachment disorders in infancy and childhood". In Rutter M, Taylor E, (Eds.) Child and Adolescent Psychiatry:
Modern Approaches (4th ed.) Blackwell Scientific publications. pp. 776-792. ISBN 0-632-01229-3
[98] Boris NW, Zeanah CH, Larrieu JA, Scheeringa MS, Heller SS (1 February 1998). "Attachment disorders in infancy and early childhood: a
preliminary investigation of diagnostic criteria" (http:/ / ajp. psychiatryonline. org/ cgi/ pmidlookup?view=long& pmid=9464217). Am J
Psychiatry 155 (2): 29597. PMID9464217. . Retrieved 2008-01-31.
[99] Boris NW, Zeanah CH (1999). "Disturbance and disorders of attachment in infancy: An overview". Infant Mental Health Journal 20: 19.
doi:10.1002/(SICI)1097-0355(199921)20:1<1::AID-IMHJ1>3.0.CO;2-V.
[100] Zeanah CH (2000). "Disturbances and disorders of attachment in early childhood". In Zeanah CH (Ed.) Handbook of infant mental health
(2nd ed.) pp. 35862. New York: Guilford Press. ISBN 1-59385-171-5
[101] Schechter DS, Willheim E (2009). Disturbances of attachment and parental psychopathology in early childhood. Infant and Early
Childhood Mental Health Issue. Child and Adolescent Psychiatry Clinics of North America, 18(3), 665-687.
[102] Greenberg MT (1999). Attachment and Psychopathology in Childhood. In Cassidy J and Shaver PR (Eds.) Handbook of Attachment:
Theory, Research and Clinical Applications. pp. 46996. Guilford Press ISBN 1-57230-087-6
[103] Main M, Hesse E (1990) "Parents' unresolved traumatic experiences are related to infants' insecure-disorganized/disoriented attachment
status: Is frightened or frightening behavior the linking mechanism?" In Greenberg M, Cicchetti D and Cummings E (Eds.) Attachment in the
preschool years: Theory, research and intervention, pp. 161182 Chicago: University of Chicago Press. ISBN 0-226-30630-5.
[104] DSM-V Proposed Draft. Reactive attachment disorder (http:/ / www. dsm5. org/ ProposedRevisions/ Pages/ proposedrevision.
aspx?rid=120). American Psychiatric Association. Charles H. Zeanah.
References
American Psychiatric Association (1994). DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders.
4th edition. Text Revision Washington, DC: American Psychiatric Association. ISBN 0-89042-025-4
Bowlby J [1969] (1997). Attachment and Loss: Attachment Vol 1 (Attachment and Loss). Pimlico; New Ed edition
ISBN 0-7126-7471-3
Bowlby J (1973). Attachment and Loss: Separation Anxiety and Anger v. 2 (International Psycho-Analysis
Library). London: Hogarth Press. ISBN 0-7012-0301-3
Bowlby J (1980). Attachment and Loss: Loss Sadness and Depression v. 3 (International Psycho-Analysis
Library). London: Hogarth Press. ISBN 0-7012-0350-1
Chaffin M, Hanson R, Saunders BE, et al. (2006). "Report of the APSAC task force on attachment therapy,
reactive attachment disorder, and attachment problems". Child Maltreat 11 (1): 7689.
doi:10.1177/1077559505283699. PMID16382093.
Mercer J (2006). Understanding Attachment: Parenting, child care and emotional development. Westport, CT:
Praeger. ISBN 0-275-98217-3
Prior V, Glaser D (2006). Understanding Attachment and Attachment Disorders. Theory, Evidence and Practice.
Child and Adolescent Mental Health series, RCPRTU, Jessica Kingsley Publishers. ISBN 978-1-84310-245-8
(pbk)
289
290

Disinhibited
attachment disorder
ICD-10
F94.2
[2]
Disinhibited attachment disorder of childhood (DAD) according to the International Classification of Diseases
(ICD-10), is defined as:
"A particular pattern of abnormal social functioning that arises during the first five years of life and that tends
to persist despite marked changes in environmental circumstances, e.g. diffuse, nonselectively focused
attachment behaviour, attention-seeking and indiscriminately friendly behaviour, poorly modulated peer
interactions; depending on circumstances there may also be associated emotional or behavioural disturbance."
F94.2 [1] of the ICD-10.
Disinhibited attachment disorder is a subtype of the ICD-10 category F94, "Disorders of social functioning with
onset specific to childhood and adolescence". The other subtype of F94 is reactive attachment disorder of childhood
(RAD F94 .1).
Synonymous or similar disorders include Affectionless psychopathy and Institutional syndrome.
Within the ICD-10 category scheme, disinhibited attachment disorder specifically excludes Asperger syndrome
(F84.5), hospitalism in children (F43.2), and hyperkinetic disorders (F90.-).
Comparison with the DSM-IV

The DSM-IV distinguishes two categories of RAD: an inhibited subtype and a disinhibited subtype (in the DSM it is
listed as 313.89 under infant diagnoses). The ICD-10 describes the former, emotionally withdrawn subtype as RAD
and the latter subtype as Disinhibited Attachment Disorder (DAD) (Zeanah et al., 2004).
Generally, the DSM-IV criteria for the inhibited subtype of RAD were generated by studies done on children who
were maltreated or abused. Criteria for the DSM-IV disinhibited subtype of RAD were based on research on children
raised in institutions (Zeanah, 1996). This is largely based on the fact that inhibited subtype of RAD is more
prevalent in maltreated children, and the disinhibited subtype of RAD is more prevalent in children raised in
institutions (Zeanah, 2000).
Studies
In a study by Zeanah, (Zeanah et al., 2004) on reactive attachment disorder in maltreated toddlers, the criteria for
DSM-IV disinhibited RAD (i.e. disinhibited attachment disorder) were:
1.
2.
3.
4.
not having a discriminated, preferred attachment figure,

not checking back after venturing away from the caregiver,
lack of reticence with unfamiliar adults,
a willingness to go off with relative strangers.
For comparison, the criteria for DSM-IV inhibited RAD were:

1.
2.
3.
4.
absence of a discriminated, preferred adult,

lack of comfort seeking for distress,
failure to respond to comfort when offered,
lack of social and emotional reciprocity, and

5. emotion regulation difficulties.
The authors found that these two disorders were not completely independent; a few children may exhibit symptoms
of both types of the disorder.
Sources
Zeanah CH (1996). "Beyond insecurity: a reconceptualization of attachment disorders of infancy" [2] (PDF). J
Consult Clin Psychol 64 (1): 4252. doi:10.1037/0022-006X.64.1.42. PMID8907083. Retrieved 2007-02-06.
Zeanah CH (2000). "Disturbances of attachment in young children adopted from institutions". J Dev Behav
Pediatr 21 (3): 23036. PMID10883884.
Zeanah CH, Scheeringa M, Boris NW, Heller SS, Smyke AT, Trapani J (August 2004). "Reactive attachment
disorder in maltreated toddlers". Child Abuse Negl 28 (8): 87788. doi:10.1016/j.chiabu.2004.01.010.
PMID15350771.
References
[1] http:/ / www. who. int/ classifications/ apps/ icd/ icd10online/ ?gf90. htm+ f942
[2] http:/ / imagesrvr. epnet. com/ embimages/ pdh2/ ccp/ ccp64142. pdf
These walls are funny. First you hate them, then you get used to them. After long enough, you get so you depend on them. That's
"institutionalized."
"Red" Redding (played by Morgan Freeman), The Shawshank Redemption
In clinical and abnormal psychology, institutional syndrome refers to deficits or disabilities in social and life skills,
which develop after a person has spent a long period living in mental hospitals, prisons, or other remote institutions.
In other words, individuals in institutions may be deprived (unintentionally) of independence and of responsibility, to
the point that once they return to "outside life" they are often unable to manage many of its demands;[1] [2] it has also
been argued that institutionalized individuals become psychologically more prone to mental health problems.[3]
The term institutionalization can both be used to the process of committing an individual to a mental hospital or
prison or to institutional syndrome; thus the phrase "X is institutionalized" may mean either that X has been placed
in an institution, or that X is suffering the psychological effects of having been in an institution for an extended
period of time.
Background
Further information: Psychiatric hospital
In Europe and North America, the trend of putting the mentally ill into mental hospitals began as early as the 17th
century,[4] and hospitals often focused more on "restraining" or controlling inmates than on curing them,[5] although
hospital conditions improved somewhat with movements for human treatment, such as moral management. By the
mid-20th century, overcrowding in institutions,[6] [7] the failure of institutional treatment to cure most mental
illnesses,[6] and the advent of drugs such as Thorazine[7] prompted many hospitals to begin discharging patients in
large numbers, in the beginning of the deinstitutionalization movement (the process of gradually moving people
from inpatient care in mental hospitals, to outpatient care).
Deinstitutionalization did not always result in better treatment, however, and in many ways it helped reveal some of
the shortcomings of institutional care, as discharged patients were often unable to take care of themselves, and many
ended up homeless or in jail.[8] In other words, many of these patients had become "institutionalized" and were
291
unable to adjust to independent living. One of the first studies to address the issue of institutionalization directly was
Russel Barton's 1962 book Institutional Neurosis, which claimed that many symptoms of mental illness (specifically,
psychosis) were not physical brain defects as once thought, but were consequences of institutions' "stripping" away
the "psychological crutches" of their patients.[1]
Since the middle of the 20th century, the problem of institutionalization has been one of the motivating factors for
the increasing popularity of deinstitutionalization and the growth of community mental health services,[2] [9] since
some mental healthcare providers believe that institutional care may create as many problems as it solves.
Issues for discharged patients

Individuals who suffer from institutional syndrome can face several kinds of difficulties upon returning to the
community. The lack of independence and responsibility for patients within institutions, along with the
"depressing"[6] and "dehumanizing"[7] environment, can make it difficult for patients to live and work independently.
Furthermore, the experience of being in an institution may often have exacerbated individuals' illness: proponents of
labeling theory claim that individuals who are socially "labeled" as mentally ill suffer stigmatization and alienation
that lead to psychological damage and a lessening of self-esteem, and thus that being placed in a mental health
institution can actually cause individuals to become more mentally ill.[10] [11]
Notes
[1]
[2]
[3]
[4]
Williams (1994, pp.835)

Solving Mental Health Problems (2001)
Leite & Schmid (2004)
Nemade, Rashmi; Dombeck, Mark (14 February 2006), "Institutionalization and Deinstitutionalization with Schizophrenia" (http:/ / www.
mentalhelp. net/ poc/ view_doc. php?type=doc& id=8813& cn=7), MentalHealth.net, , retrieved 11 June 2009
[5] Grob 1994, p.104
[6] Grob 1994, p.127
[7] Palmer, Ann, 20th Century History of the Treatment of Mental Illness: A Review (http:/ / web. archive. org/ web/ 20040710022826/ http:/ /
www. mentalhealthworld. org/ 29ap. html), archived from the original (http:/ / www. mentalhealthworld. org/ 29ap. html) on 10 July 2004, ,
retrieved 11 June 2009
[8] Shorter 1997, p.280
[9] Williams (1994, p.151)
[10] Wright, Eric R; Gronfein, William P; Owens, Timothy J (2000), "Deinstitutionalization, social rejection, and the self-esteem of former
mental patients", Journal of Health and Social Behavior (American Sociological Association) 41 (1): 6890, doi:10.2307/2676361,
JSTOR2676361
[11] Link, Bruce G; Cullen, Francis T; Struening, Elmer; Shrout, Patrick E; Dohrenwend, Bruce P (1989), "A Modified Labeling Theory
Approach to Mental Disorders: An Empirical Assessment", American Sociological Review (American Sociological Association) 54 (3):
400423, doi:10.2307/2095613, JSTOR2095613
References
Grob, Gerald N (1994), The Mad Among Us: A History of the Care of Americas Mentally Ill (http://books.
google.com/books?id=VQF1IAbZFuYC), New York: The Free Press
Leite, Ligia Costa; Schmid, Patricia C. (2004), "Institutionalization and Psychological Suffering: Notes on the
Mental Health of Institutionalized Adolescents in Brazil", Transcultural Psychiatry 41 (2): 281293,
doi:10.1177/1363461504043569
Shorter, Edward (1997), A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (http://books.
google.com/books?id=-Oybg_APowMC), New York: John Wiley & Sons
"Solving Mental Health Problems" (http://www.who.int/whr/2001/chapter3/en/index.html), Mental Health:
New Understanding, New Hope, The World Health Report, World Health Organization, 2001
Williams, Stephen M. (1994), Environment and Mental Health, New York: John Wiley & Sons
292
293

Fetal Alcohol Syndrome (FAS)
Facial characteristics of a child with FAS

[1]
ICD-10
Q86.0
ICD-9
760.71
DiseasesDB
32957
MedlinePlus
000911
eMedicine
ped/767
MeSH
D005310
[2]
[3]
[4]
[5]
[6]
Fetal alcohol syndrome (FAS) is a pattern of mental and physical defects that can develop in a fetus in association
with high levels of alcohol consumption during pregnancy. Current research also implicates other lifestyle choices
made by the prospective mother (see below). Indications for lower levels of alcohol are inconclusive [7] The current
recommendation of both the Surgeon General of the United States and the British Department of Health is to drink
no alcohol at all during pregnancy.[8] [9] [10]
Alcohol crosses the placental barrier and can stunt fetal growth or weight, create distinctive facial stigmata, damage
neurons and brain structures, which can result in psychological or behavioral problems, and cause other physical
damage.[11] [12] [13] Surveys found that in the United States, 1015% of pregnant women report having recently used
alcohol, and up to 30% use alcohol at some point during pregnancy.[14] [15] [16]
The main effect of FAS is permanent central nervous system damage, especially to the brain. Developing brain cells
and structures can be malformed or have development interrupted by prenatal alcohol exposure; this can create an
array of primary cognitive and functional disabilities (including poor memory, attention deficits, impulsive behavior,
and poor cause-effect reasoning) as well as secondary disabilities (for example, predispositions to mental health
problems and drug addiction).[13] [17] Alcohol exposure presents a risk of fetal brain damage at any point during a
pregnancy, since brain development is ongoing throughout pregnancy.[18]
Fetal alcohol exposure is the leading known cause of intellectual disability in the Western world.[19] [20] In the
United States and Europe, the FAS prevalence rate is estimated to be between 0.2-1.5 in every 1000 live births.[21]
The lifetime medical and social costs of FAS are estimated to be as high as US$800,000 per child born with the
disorder.[22]
294
Signs and symptoms

Growth deficiency
Growth deficiency is defined as below average height, weight or both due to prenatal alcohol exposure, and can be
assessed at any point in the lifespan. Growth measurements must be adjusted for parental height, gestational age (for
a premature infant), and other postnatal insults (e.g., poor nutrition), although birth height and weight are the
preferred measurements.[23] Deficiencies are documented H191 when height or weight falls at or below the 10th
percentile of standardized growth charts appropriate to the patient's population.[24]
The CDC and Canadian guidelines use the 10th percentile as a cut-off to determine growth deficiency.[25] [26] The
"4-Digit Diagnostic Code" allows for mid-range gradations in growth deficiency (between the 3rd and 10th
percentiles) and severe growth deficiency at or below the 3rd percentile.[23] Growth deficiency (at severe, moderate,
or mild levels) contributes to diagnoses of FAS and PFAS (Partial Fetal Alcohol Syndrome), but not ARND
(Alcohol-Related Neurodevelopmental Disorder) or static encephalopathy.
Growth deficiency is ranked as follows by the "4-Digit Diagnostic Code:"[23]
Severe Height and weight at or below the 3rd percentile.
Moderate Either height or weight at or below the 3rd percentile, but not both.
Mild Both height and weight between the 3rd and 10th percentiles.
None Height and weight both above the 10th percentile.
Facial features
Several characteristic craniofacial abnormalities are often visible in
individuals with FAS.[27] The presence of FAS facial features indicates
brain damage, though brain damage may also exist in their absence.
FAS facial features (and most other visible, but non-diagnostic,
deformities) are believed to be caused mainly during the 10th and 20th
week of gestation.[28]
Refinements in diagnostic criteria since 1975 have yielded three
distinctive and diagnostically significant facial features known to result
from prenatal alcohol exposure and distinguishes FAS from other
disorders with partially overlapping characteristics.[29] [30] The three
FAS facial features are:
A smooth philtrum The divot or groove between the nose and
upper lip flattens with increased prenatal alcohol exposure.
Thin vermilion The upper lip thins with increased prenatal
alcohol exposure.
Baby with Fetal alcohol syndrome.
Small palpebral fissures Eye width decreases with increased prenatal alcohol exposure.
Measurement of FAS facial features uses criteria developed by the University of Washington. The lip and philtrum
are measured by a trained physician with the Lip-Philtrum Guide,[31] a 5-point Likert Scale with representative
photographs of lip and philtrum combinations ranging from normal (ranked 1) to severe (ranked 5). Palpebral fissure
length (PFL) is measured in millimeters with either calipers or a clear ruler and then compared to a PFL growth
chart, also developed by the University of Washington.[32]
Ranking FAS facial features is complicated because the three separate facial features can be affected independently
by prenatal alcohol. A summary of the criteria follows:[23] [33]

Severe All three facial features ranked independently as severe (lip ranked at 4 or 5, philtrum ranked at 4 or 5,
and PFL two or more standard deviations below average).
Moderate Two facial features ranked as severe and one feature ranked as moderate (lip or philtrum ranked at
3, or PFL between one and two standard deviations below average).
Mild A mild ranking of FAS facial features covers a broad range of facial feature combinations:
Two facial features ranked severe and one ranked within normal limits,
One facial feature ranked severe and two ranked moderate, or
One facial feature ranked severe, one ranked moderate and one ranked within normal limits.
None All three facial features ranked within normal limits.
These distinctive facial features in a patient do strongly correlate to brain damage. Sterling Clarren of the University
of Washington's Fetal Alcohol and Drug Unit told a conference in 2002:
I have never seen anybody with this whole face who doesn't have some brain damage. In fact in studies,
as the face is more FAS-like, the brain is more likely to be abnormal. The only face that you would want
to counsel people or predict the future about is the full FAS face. But the risk of brain damage increases
as the eyes get smaller, as the philtrum gets flatter, and the lip gets thinner. The risk goes up but not the
diagnosis.
At one-month gestation, the top end of your body is a brain, and at the very front end of that early
brain, there is tissue that has been brain tissue. It stops being brain and gets ready to be your face ...
Your eyeball is also brain tissue. It's an extension of the second part of the brain. It started as brain and
"popped out." So if you are going to look at parts of the brain from alcohol damage, or any kind of
damage during pregnancy, eye malformations and midline facial malformations are going to be very
actively related to the brain across syndromes ... and they certainly are with FAS.[34]
Central nervous system

Central nervous system (CNS) damage is the primary feature of any Fetal Alcohol Spectrum Disorder (FASD)
diagnosis. Prenatal exposure to alcohol which is classified as a teratogen can damage the brain across a
continuum of gross to subtle impairments, depending on the amount, timing, and frequency of the exposure as well
as genetic predispositions of the fetus and mother.[10] [35] While functional abnormalities are the behavioral and
cognitive expressions of the FAS disability, CNS damage can be assessed in three areas: structural, neurological, and
functional impairments.
All four diagnostic systems allow for assessment of CNS damage in these areas, but criteria vary. The IOM system
requires structural or neurological impairment for a diagnosis of FAS.[10] The "4-Digit Diagnostic Code" and CDC
guidelines state that functional anomalies must measure at two standard deviations or worse in three or more
functional domains for a diagnosis of FAS.[23] [25] The "4-Digit Diagnostic Code" further elaborates the degree of
CNS damage according to four ranks:
Definite Structural impairments or neurological impairments for FAS or static encephalopathy.
Probable Significant dysfunction of two standard deviations or worse in three or more functional domains.
Possible Mild to moderate dysfunction of two standard deviations or worse in one or two functional domains
or by judgment of the clinical evaluation team that CNS damage cannot be dismissed.
Unlikely No evidence of CNS damage.
295

Structural
Structural abnormalities of the brain are observable, physical damage to the brain or brain structures caused by
prenatal alcohol exposure. Structural impairments may include microcephaly (small head size) of two or more
standard deviations below the average, or other abnormalities in brain structure (e.g., agenesis of the corpus
callosum, cerebellar hypoplasia).[10]
Microcephaly is determined by comparing head circumference (often called occipitofrontal circumference, or OFC)
to appropriate OFC growth charts.[24] Other structural impairments must be observed through medical imaging
techniques by a trained physician. Because imaging procedures are expensive and relatively inaccessible to most
patients, diagnosis of FAS is not frequently made via structural impairments, except for microcephaly.
Evidence of a CNS structural impairment due to prenatal alcohol exposure will result in a diagnosis of FAS, and
neurological and functional impairments are highly likely.[10] [23] [25] [26]
During the first trimester of pregnancy, alcohol interferes with the migration and organization of brain cells, which
can create structural deformities or deficits within the brain.[36] During the third trimester, damage can be caused to
the hippocampus, which plays a role in memory, learning, emotion, and encoding visual and auditory information,
all of which can create neurological and functional CNS impairments as well.[37]
As of 2002, there were 25 reports of autopsies on infants known to have FAS. The first was in 1973, on an infant
who died shortly after birth.[38] The examination revealed extensive brain damage, including microcephaly,
migration anomalies, callosal dysgenesis, and a massive neuroglial, leptomeningeal heterotopia covering the left
hemisphere.[39]
In 1977, Dr. Clarren described a second infant whose mother was a binge drinker. The infant died ten days after
birth. The autopsy showed severe hydrocephalus, abnormal neuronal migration, and a small corpus callosum (which
connects the two brain hemispheres) and cerebellum.[39] FAS has also been linked to brainstem and cerebellar
changes, agenesis of the corpus callosum and anterior commissure, neuronal migration errors, absent olfactory bulbs,
meningomyelocele, and porencephaly.[39]
Neurological
When structural impairments are not observable or do not exist, neurological impairments are assessed. In the
context of FAS, neurological impairments are caused by prenatal alcohol exposure which causes general
neurological damage to the central nervous system (CNS) and the peripheral nervous system (PNS). A determination
of a neurological problem must be made by a trained physician, and must not be due to a postnatal insult, such as a
high fever, concussion, traumatic brain injury, etc.
All four diagnostic systems show virtual agreement on their criteria for CNS damage at the neurological level, and
evidence of a CNS neurological impairment due to prenatal alcohol exposure will result in a diagnosis of FAS, and
functional impairments are highly likely.[10] [23] [25] [26]
Neurological problems are expressed as either hard signs, or diagnosable disorders, such as epilepsy or other seizure
disorders, or soft signs. Soft signs are broader, nonspecific neurological impairments, or symptoms, such as impaired
fine motor skills, neurosensory hearing loss, poor gait, clumsiness, poor eye-hand coordination. Many soft signs
have norm-referenced criteria, while others are determined through clinical judgment. "Clinical judgment" is only as
good as the clinician, and soft signs should be assessed by either a pediatric neurologist, a pediatric
neuropsychologist, or both. Those affected have mild retardation.
296

Functional
When structural or neurological impairments are not observed, all four diagnostic systems allow CNS damage due to
prenatal alcohol exposure to be assessed in terms of functional impairments.[10] [23] [25] [26] Functional impairments
are deficits, problems, delays, or abnormalities due to prenatal alcohol exposure (rather than hereditary causes or
postnatal insults) in observable and measurable domains related to daily functioning, often referred to as
developmental disabilities. There is no consensus on a specific pattern of functional impairments due to prenatal
alcohol exposure[10] and only CDC guidelines label developmental delays as such,[25] so criteria vary somewhat
across diagnostic systems.
The four diagnostic systems list various CNS domains that can qualify for functional impairment that can determine
an FAS diagnosis:
Evidence of a complex pattern of behavior or cognitive abnormalities inconsistent with developmental level in the
following CNS domains sufficient for a PFAS (partial fetal alcohol syndrome) or ARND (alcohol-related
neurodevelopmental disorder) diagnosis using IOM guidelines[10]
Learning disabilities, academic achievement, impulse control, social perception, communication, abstraction,
math skills, memory, attention, judgment
Performance at two or more standard deviations on standardized testing in three or more of the following CNS
domains sufficient for a FAS, PFAS or static encephalopathy diagnosis using 4-Digit Diagnostic Code[23]
Executive functioning, memory, cognition, social/adaptive skills, academic achievement, language, motor
skills, attention, activity level
General cognitive deficits (e.g., IQ) at or below the 3rd percentile on standardized testing sufficient for an FAS
diagnosis using CDC guidelines[25]
Performance at or below the 16th percentile on standardized testing in three or more of the following CNS
domains sufficient for an FAS diagnosis using CDC guidelines[25]
Cognition, executive functioning, motor functioning, attention and hyperactive problems, social skills, sensory
integration dysfunction, social communication, memory, difficulties responding to common parenting practices
domains sufficient for an FAS diagnosis using Canadian guidelines
Cognition, communication, academic achievement, memory, executive functioning, adaptive behavior, social
skills, social communication
Related signs
Other conditions may commonly co-occur with FAS, stemming from prenatal alcohol exposure. However, these
conditions are considered Alcohol-Related Birth Defects[10] and not diagnostic criteria for FAS.
Cardiac A heart murmur that frequently disappears by one year of age. Ventricular septal defect most
commonly seen, followed by an atrial septal defect.
Skeletal Joint anomalies including abnormal position and function, altered palmar crease patterns, small distal
phalanges, and small fifth fingernails.
Renal Horseshoe, aplastic, dysplastic, or hypoplastic kidneys.
Ocular Strabismus, optic nerve hypoplasia[40] (which may cause light sensitivity, decreased visual acuity, or
involuntary eye movements).
Occasional abnormalities ptosis of the eyelid, microophthalmia, cleft lip with or without a cleft palate, webbed
neck, short neck, tetralogy of Fallot, coarctation of the aorta, spina bifida, and hydrocephalus.
297
Cause
Prenatal alcohol exposure is the cause of fetal alcohol syndrome. A study of over 400,000 American women, all of
whom had consumed alcohol during pregnancy, concluded that consumption of 15 drinks or more per week was
associated with a reduction in birth weight.[41] Though consumption of less than 15 drinks per week was not proven
to cause FAS-related effects, the study authors recommend limiting consumption to no more than one standard drink
per day.[41] Also, threshold values are based upon group averages, and it is not appropriate to conclude that exposure
below this threshold is necessarily safe because of the significant individual variations in alcohol
pharmacokinetics.[41]
An analysis of seven medical research studies involving over 130,000 pregnancies found that consuming two to 14
drinks per week did not significantly increase the risk of giving birth to a child with either malformations or fetal
alcohol syndrome.[42] Pregnant women who consume approximately 18 drinks per day have a 30-33% chance of
having a baby with FAS.[41]
A number of studies have shown that light drinking (1-2 drinks/week) during pregnancy does not appear to pose a
risk to the fetus.[43] [44] [45] [46] A study of pregnancies in eight European countries found that consuming no more
than one drink per day did not appear to have any effect on fetal growth.
A follow-up of children at 18 months of age found that those from women who drank during pregnancy, even two
drinks per day, scored higher in several areas of development,[47] though in a different study, as little as one drink
per day resulted in poorer spelling and reading abilities at age 6 and a linear dose-response relationship was seen
between prenatal alcohol exposure and poorer arithmetic scores at the same age.[48]
Diagnosis
Several diagnostic systems have been developed in North America:
The Institute of Medicine's guidelines for FAS, the first system to standardize diagnoses of individuals with
prenatal alcohol exposure,[10]
The University of Washington's "The 4-Digit Diagnostic Code," which ranks the four key features of FASD on a
Likert scale of one to four and yields 256 descriptive codes that can be categorized into 22 distinct clinical
categories, ranging from FAS to no findings.[23]
The Centers for Disease Control's "Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis," which
established general consensus on the diagnosis FAS in the U.S. but deferred addressing other FASD
conditions,[25] and
Canadian guidelines for FASD diagnosis, which established criteria for diagnosing FASD in Canada and
harmonized most differences between the IOM and University of Washington's systems.[26]
Fetal alcohol syndrome is the only expression of FASD that has garnered consensus among experts to become an
official ICD-9 and ICD-10 diagnosis. To make this diagnosis (or determine any FASD condition), a
multi-disciplinary evaluation is necessary to assess each of the four key features for assessment. Generally, a trained
physician will determine growth deficiency and FAS facial features. While a qualified physician may also assess
central nervous system structural abnormalities and/or neurological problems, usually central nervous system
damage is determined through psychological assessment. A pediatric neuropsychologist may assess all areas of
functioning, including intellectual, language processing, and sensorimotor. Prenatal alcohol exposure risk may be
assessed by a qualified physician or psychologist.
The following criteria must be fully met for an FAS diagnosis:[10] [23] [25] [26]
1. Growth deficiency Prenatal or postnatal height or weight (or both) at or below the 10th percentile[24]
2. FAS facial features All three FAS facial features present[32]
3. Central nervous system damage Clinically significant structural, neurological, or functional impairment
4. Prenatal alcohol exposure Confirmed or Unknown prenatal alcohol exposure
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Alcohol intake is determined by interview of the biological mother or other family members knowledgeable of the
mother's alcohol use during the pregnancy, prenatal health records, and review of available birth records, court
records, chemical dependency treatment records, or other reliable sources. Exposure level is assessed as Confirmed
Exposure, Unknown Exposure, and Confirmed Absence of Exposure by the IOM, CDC and Canadian diagnostic
systems. The "4-Digit Diagnostic Code" further distinguishes confirmed exposure as High Risk and Some Risk:
High Risk Confirmed use of alcohol during pregnancy known to be at high blood alcohol levels (100mg/dL or
greater) delivered at least weekly in early pregnancy.
Some Risk Confirmed use of alcohol during pregnancy with use less than High Risk or unknown usage
patterns.
Unknown Risk Unknown use of alcohol during pregnancy.
No Risk Confirmed absence of prenatal alcohol exposure, which rules out an FAS diagnosis.
Confirmed exposure
Amount, frequency, and timing of prenatal alcohol use can dramatically impact the other three key features of FAS.
While consensus exists that alcohol is a teratogen, there is no clear consensus as to what level of exposure is
toxic.[10] The CDC guidelines are silent on these elements diagnostically. The IOM and Canadian guidelines explore
this further, acknowledging the importance of significant alcohol exposure from regular or heavy episodic alcohol
consumption in determining, but offer no standard for diagnosis. Canadian guidelines discuss this lack of clarity and
parenthetically point out that "heavy alcohol use" is defined by the National Institute on Alcohol Abuse and
Alcoholism as five or more drinks per episode on five or more days during a 30 day period.[49]
"The 4-Digit Diagnostic Code" ranking system distinguishes between levels of prenatal alcohol exposure as High
Risk and Some Risk. It operationalizes high risk exposure as a blood alcohol concentration (BAC) greater than
100mg/dL delivered at least weekly in early pregnancy. This BAC level is typically reached by a 55kg woman
drinking six to eight beers in one sitting.[23]
Unknown exposure
For many adopted or adult patients and children in foster care, records or other reliable sources may not be available
for review. Reporting alcohol use during pregnancy can also be stigmatizing to birth mothers, especially if alcohol
use is ongoing.[25] In these cases, all diagnostic systems use an unknown prenatal alcohol exposure designation. A
diagnosis of FAS is still possible with an unknown exposure level if other key features of FASD are present at
clinical levels.
Differential diagnosis
The CDC reviewed nine syndromes that have overlapping features with FAS; however, none of these syndromes
include all three FAS facial features, and none are the result of prenatal alcohol exposure:[25]
Aarskog syndrome
Williams syndrome
Noonan syndrome
Dubowitz syndrome
Brachman-DeLange syndrome
Toluene syndrome
Fetal hydantoin syndrome
Fetal valproate syndrome
Maternal PKU fetal effects
299
Prevention
The only certain way to prevent FAS is to simply avoid drinking alcohol during pregnancy.[13] In the United States,
the Surgeon General recommended in 1981, and again in 2005, that women abstain from alcohol use while pregnant
or while planning a pregnancy, the latter to avoid damage in the earliest stages of a pregnancy, as the woman may
not be aware that she has conceived.[8] In the United States, federal legislation has required that warning labels be
placed on all alcoholic beverage containers since 1988 under the Alcoholic Beverage Labeling Act.
Treatment
There is no cure for FAS, because the CNS damage creates a permanent disability, but treatment is possible. Because
CNS damage, symptoms, secondary disabilities, and needs vary widely by individual, there is no one treatment type
that works for everyone.
Medical interventions
Traditional medical interventions (i.e., psychoactive drugs) are frequently tried on those with FAS because many
FAS symptoms are mistaken for or overlap with other disorders, most notably ADHD.[50]
Behavioral interventions
Traditional behavioral interventions are predicated on learning theory, which is the basis for many parenting and
professional strategies and interventions.[51] Along with ordinary parenting styles, such strategies are frequently used
by default for treating those with FAS, as the diagnoses Oppositional Defiance Disorder (ODD), Conduct Disorder,
Reactive Attachment Disorder (RAD), etc. often overlap with FAS (along with ADHD), and these are sometimes
thought to benefit from behavioral interventions. Frequently, a patient's poor academic achievement results in special
education services, which also utilizes principles of learning theory, behavior modification, and outcome-based
education.
Because the "learning system" of a patient with FAS is damaged, however, behavioral interventions are not always
successful, or not successful in the long run, especially because overlapping disorders frequently stem from or are
exacerbated by FAS.[51] Kohn (1999) suggests that a rewards-punishment system in general may work somewhat in
the short term but is unsuccessful in the long term because that approach fails to consider content (i.e., things
"worth" learning), community (i.e., safe, cooperative learning environments), and choice (i.e., making choices versus
following directions).[52] While these elements are important to consider when working with FAS and have some
usefulness in treatment, they are not alone sufficient to promote better outcomes.[51] Kohn's minority challenge to
behavioral interventions does illustrate the importance of factors beyond learning theory when trying to promote
improved outcomes for FAS, and supports a more multi-model approach that can be found in varying degrees within
the advocacy model and neurobehavioral approach.
Developmental framework
Many books and handouts on FAS recommend a developmental approach, based on developmental psychology,
even though most do not specify it as such and provide little theoretical background. Optimal human development
generally occurs in identifiable stages (e.g., Jean Piaget's theory of cognitive development, Erik Erikson's stages of
psychosocial development, John Bowlby's attachment framework, and other developmental stage theories). FAS
interferes with normal development,[53] which may cause stages to be delayed, skipped, or immaturely developed.
Over time, an unaffected child can negotiate the increasing demands of life by progressing through stages of
development normally, but not so for a child with FAS.[53]
By knowing what developmental stages and tasks children follow, treatment and interventions for FAS can be
tailored to helping a patient meet developmental tasks and demands successfully.[53] If a patient is delayed in the
300

adaptive behavior domain, for instance, then interventions would be recommended to target specific delays through
additional education and practice (e.g., practiced instruction on tying shoelaces), giving reminders, or making
accommodations (e.g., using slip-on shoes) to support the desired functioning level. This approach is an advance
over behavioral interventions, because it takes the patient's developmental context into account while developing
interventions.
Advocacy model
The advocacy model takes the point of view that someone is needed to actively mediate between the environment
and the person with FAS.[13] Advocacy activities are conducted by an advocate (for example, a family member,
friend, or case manager) and fall into three basic categories. An advocate for FAS: (1) interprets FAS and the
disabilities that arise from it and explains it to the environment in which the patient operates, (2) engenders change
or accommodation on behalf of the patient, and (3) assists the patient in developing and reaching attainable goals.[13]
The advocacy model is often recommended, for example, when developing an Individualized Education Program
(IEP) for the patient's progress at school.[50]
An understanding of the developmental framework would presumably inform and enhance the advocacy model, but
advocacy also implies interventions at a systems level as well, such as educating schools, social workers, and so
forth on best practices for FAS. However, several organizations devoted to FAS also use the advocacy model at a
community practice level as well.[54]
Neurobehavioral approach
The neurobehavioral approach focuses on the neurological underpinnings from which behaviors and cognitive
processes arise.[51] It is an integrative perspective that acknowledges and encourages a multi-modal array of
treatment interventions that draw from all FAS treatment approaches. The neurobehavioral approach is a serious
attempt at shifting single-perspective treatment approaches into a new, coherent paradigm that addresses the
complexities of problem behaviors and cognitions emanating from the CNS damage of FAS.
The neurobehavioral approach's main proponent is Diane Malbin, MSW, a recognized speaker and trainer in the
FASD field, who first articulated the approach with respect to FASD and characterizes it as "Trying differently
rather than trying harder."[55] The idea to try differently refers to trying different perspectives and intervention
options based on effects of the CNS damage and particular needs of the patient, rather than trying harder at
implementing behavioral-based interventions that have consistently failed over time to produce improved outcomes
for a patient. This approach also encourages more strength-based interventions, which allow a patient to develop
positive outcomes by promoting success linked to the patient's strengths and interests.[51]
Public health and policy

Treating FAS at the public health and public policy levels promotes FAS prevention and diversion of public
resources to assist those with FAS.[13] It is related to the advocacy model but promoted at a systems level (rather
than with the individual or family), such as developing community education and supports, state or province level
prevention efforts (e.g., screening for maternal alcohol use during OB/GYN or prenatal medical care visits), or
national awareness programs. Several organizations and state agencies in the U.S. are dedicated to this type of
intervention.[54]
301
Prognosis
Primary disabilities
The primary disabilities of FAS are the functional difficulties with which the child is born as a result of CNS damage
due to prenatal alcohol exposure.[17] Often, primary disabilities are mistaken as behavior problems, but the
underlying CNS damage is the originating source of a functional difficulty[56] (rather than a mental health condition,
which is considered a secondary disability).
The exact mechanisms for functional problems of primary disabilities are not always fully understood, but animal
studies have begun to shed light on some correlates between functional problems and brain structures damaged by
prenatal alcohol exposure.[13] Representative examples include:
Learning impairments are associated with impaired dendrites of the hippocampus[57]
Impaired motor development and functioning are associated with reduced size of the cerebellum[58]
Hyperactivity is associated with decreased size of the corpus callosum[59]
Functional difficulties may result from CNS damage in more than one domain, but common functional difficulties by
domain include:[13] [51] [53] [56] (This is not an exhaustive list of difficulties.)
Achievement Learning disabilities
Adaptive behavior Poor impulse control, poor personal boundaries, poor anger management, stubbornness,
intrusive behavior, too friendly with strangers, poor daily living skills, developmental delays
Attention Attention-Deficit/Hyperactivity Disorder (ADHD), poor attention or concentration, distractible
Cognition Mental retardation, confusion under pressure, poor abstract skills, difficulty distinguishing between
fantasy and reality, slower cognitive processing
Executive functioning Poor judgment, Information-processing disorder, poor at perceiving patterns, poor cause
and effect reasoning, inconsistent at linking words to actions, poor generalization ability
Language Expressive or receptive language disorders, grasp parts but not whole concepts, lack understanding
of metaphor, idioms, or sarcasm
Memory Poor short-term memory, inconsistent memory and knowledge base
Motor skills Poor handwriting, poor fine motor skills, poor gross motor skills, delayed motor skill
development (e.g., riding a bicycle at appropriate age)
Sensory integration and soft neurological problems sensory integration dysfunction, sensory defensiveness,
undersensitivity to stimulation
Social communication Intrude into conversations, inability to read nonverbal or social cues, "chatty" but
without substance
Secondary disabilities
The secondary disabilities of FAS are those that arise later in life secondary to CNS damage. These disabilities often
emerge over time due to a mismatch between the primary disabilities and environmental expectations; secondary
disabilities can be ameliorated with early interventions and appropriate supportive services.[17]
Six main secondary disabilities were identified in a University of Washington research study of 473 subjects
diagnosed with FAS, PFAS (partial fetal alcohol syndrome), and ARND (alcohol-related neurodevelopmental
disorder):[13] [17]
Mental health problems Diagnosed with ADHD, Clinical Depression, or other mental illness, experienced by
over 90% of the subjects
Disrupted school experience Suspended or expelled from school or dropped out of school, experienced by 60%
of the subjects (age 12 and older)
302

Trouble with the law Charged or convicted with a crime, experienced by 60% of the subjects (age 12 and
older)
Confinement For inpatient psychiatric care, inpatient chemical dependency care, or incarcerated for a crime,
experienced by about 50% of the subjects (age 12 and older)
Inappropriate sexual behavior Sexual advances, sexual touching, or promiscuity, experienced by about 50% of
the subjects (age 12 and older)
Alcohol and drug problems Abuse or dependency, experienced by 35% of the subjects (age 12 and older)
Two additional secondary disabilities exist for adult patients:[13] [17]
Dependent living Group home, living with family or friends, or some sort of assisted living, experienced by
80% of the subjects (age 21 and older)
Problems with employment Required ongoing job training or coaching, could not keep a job, unemployed,
experienced by 80% of the subjects (age 21 and older)
Protective factors and strengths

Eight factors were identified in the same study as universal protective factors that reduced the incidence rate of the
secondary disabilities:[13] [17]
Living in a stable and nurturant home for over 72% of life

Being diagnosed with FAS before age six
Never having experienced violence
Remaining in each living situation for at least 2.8 years
Experiencing a "good quality home" (meeting 10 or more defined qualities) from age 8 to 12 years old
Having been found eligible for developmental disability (DD) services
Having basic needs met for at least 13% of life
Having a diagnosis of FAS (rather than another FASD condition)
Malbin (2002) has identified the following areas of interests and talents as strengths that often stand out for those
with FASD and should be utilized, like any strength, in treatment planning:[51]
Music, playing instruments, composing, singing, art, spelling, reading, computers, mechanics, woodworking,
skilled vocations (welding, electrician, etc.), writing, poetry
History
Historical references
Anecdotal accounts of prohibitions against maternal alcohol use from Biblical, ancient Greek, and ancient Roman
sources imply a historical awareness of links between maternal alcohol use and negative child outcomes.[38] In
Gaelic Scotland, the mother and nurse were not allowed to consume ale during pregnancy and breastfeeding (Martin
Martin).
The earliest recorded observation of possible links between maternal alcohol use and fetal damage was made in 1899
by Dr. William Sullivan, a Liverpool prison physician who noted higher rates of stillbirth for 120 alcoholic female
prisoners than their sober female relatives; he suggested the causal agent to be alcohol use.[60] This contradicted the
predominating belief at the time that heredity caused mental retardation, poverty, and criminal behavior, which
contemporary studies on the subjects usually concluded.[13] A case study by Henry H. Goddard of the Kallikak
family popular in the early 1900s represents this earlier perspective,[61] though later researchers have
suggested that the Kallikaks almost certainly had FAS.[62] General studies and discussions on alcoholism throughout
the mid-1900s were typically based on a heredity argument.[63]
303

Prior to fetal alcohol syndrome being specifically identified and named in 1973, a few studies had noted differences
between the children of mothers who used alcohol during pregnancy or breast-feeding and those who did not, but
identified alcohol use as a possible contributing factor rather than heredity.[13]
Recognition as a syndrome
Fetal Alcohol Syndrome was named in 1973 by two dysmorphologists, Drs. Kenneth Lyons Jones and David Weyhe
Smith of the University of Washington Medical School in Seattle, United States. They identified a pattern of
"craniofacial, limb, and cardiovascular defects associated with prenatal onset growth deficiency and developmental
delay" in eight unrelated children of three ethnic groups, all born to mothers who were alcoholics.[64] The pattern of
malformations indicated that the damage was prenatal. News of the discovery shocked some, while others were
skeptical of the findings.[65]
Dr. Paul Lemoine of Nantes, France had already published a study in a French medical journal in 1968 about
children with distinctive features whose mothers were alcoholics,[12] and in the U.S., Christy Ulleland and colleagues
at the University of Washington Medical School[11] had conducted an 18-month study in 19681969 documenting
the risk of maternal alcohol consumption among the offspring of 11 alcoholic mothers. The Washington and Nantes
findings were confirmed by a research group in Gothenburg, Sweden in 1979.[66] Researchers in France, Sweden,
and the United States were struck by how similar these children looked, though they were not related, and how they
behaved in the same unfocused and hyperactive manner.[66]
Within nine years of the Washington discovery, animal studies, including non-human monkey studies carried out at
the University of Washington Primate Center by Dr. Sterling Clarren, had confirmed that alcohol was a teratogen.
By 1978, 245 cases of FAS had been reported by medical researchers, and the syndrome began to be described as the
most frequent known cause of mental retardation.
While many syndromes are eponymous, i.e. named after the physician first reporting the association of symptoms,
Dr. Smith named FAS after the causal agent of the symptoms.[67] He reasoned that doing so would encourage
prevention, believing that if people knew maternal alcohol consumption caused the syndrome, then abstinence
during pregnancy would follow from patient education and public awareness.[67] Nobody was aware of the full range
of possible birth defects from FAS or its prevalence rate at that time,[67] but admission of alcohol use during
pregnancy can feel stigmatizing to birth mothers and complicate diagnostic efforts[25] of a syndrome with its
preventable cause in the name.
Over time, as subsequent research and clinical experience suggested that a range of effects (including physical,
behavioral, and cognitive) could arise from prenatal alcohol exposure, the term Fetal Alcohol Spectrum Disorder
(FASD) was developed to include FAS as well as other conditions resulting from prenatal alcohol exposure.[67]
Currently, FAS[10] [64] [68] is the only expression of prenatal alcohol exposure defined by the International Statistical
Classification of Diseases and Related Health Problems and assigned ICD-9 and diagnoses.
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[60] Sullivan, W.C. (1899). A note on the influence of maternal inebriety on the offspring. Journal of Mental Science, 45, 489503.
[61] Goddard, H.H. (1912). The Kallikak Family: A Study in the Heredity of Feeble-Mindedness. New York: Macmillan.
[62] Karp, R.J., Qazi, Q.H., Moller, K.A., Angelo, W.A., & Davis, J.M. (1995). Fetal alcohol syndrome at the turn of the century: An unexpected
explanation of the Kallikak family. Archives of Pediatrics and Adolescent Medicine, 149(1), 4548. PMID 7827659
[63] Haggard, H.W., & Jellinek, E.M. (1942). Alcohol Explored. New York: Doubleday.
[64] Jones, K.L., Smith, D.W, Ulleland, C.N., Streissguth, A.P. (1973). Pattern of malformation in offspring of chronic alcoholic mothers.
Lancet, 1, 12671271. PMID 4126070
[65] Streissguth, A.P. (2002). In A. Streissguth, & J. Kanter (Eds.), The Challenge in Fetal Alcohol Syndrome: Overcoming Secondary
Disabilities. Seattle: University of WA Press. ISBN 0-295-97650-0.
[66] Olegard, R., Sabel, K.G., Aronsson, M. Sandin, B., Johannsson, P.R., Carlsson, C., Kyllerman, M., Iversen, K. & Hrbek, A. (1979). Effects
on the child of alcohol abuse during pregnancy. Acta Paediatrica Scandinavica, 275, 112121. PMID 291283
[67] Clarren, S.K. (2005). A thirty year journey from tragedy to hope. Foreword to Buxton, B. (2005). Damaged Angels: An Adoptive Mother
Discovers the Tragic Toll of Alcohol in Pregnancy. New York: Carroll & Graf. ISBN 0-7867-1550-2.
[68] Clarren, S.K., & Smith, D.W. (1978). Fetal alcohol syndrome. New England Journal of Medicine, 298, 10631067. PMID 347295
306
External links
Information on FASD in the UK (http://www.nofas-uk.org)
Whitecrow Village FASD Society (http://www.whitecrowvillage.org)
Fetal alcohol syndrome (http://www.dmoz.org/Health/Reproductive_Health/Pregnancy_and_Birth/
Complications/Fetal_Alcohol_Syndrome//) at the Open Directory Project
Congressional Caucus on Fetal Alcohol Spectrum Disorders (http://www.house.gov/pallone/fasd_caucus/
welcome.shtml)
Fetal Alcohol Syndrome Diagnostic & Prevention Network (FAS DPN) (http://depts.washington.edu/fasdpn/)
CDCs National Center on Birth Defects and Developmental Disabilities (http://www.cdc.gov/ncbddd/fas/
default.htm)
Foetal Alcohol Syndrome Aware UK (http://www.fasaware.co.uk/)
Iceberga quarterly international educational newsletter on FASD (http://www.FASiceberg.org/)
Fetal Alcohol Syndrome prevention campaign in South Africa (http://www.fasfacts.org.za/)
Minnesota Organization on Fetal Alcohol Syndrome (http://www.mofas.org)
Canadian FASD resource [[Motherisk (http://www.motherisk.org/women/updatesDetail.
jsp?content_id=347)]]
Fetal Alcohol Syndrome (http://www.primehealthchannel.com/
fetal-alcohol-syndrome-pictures-symptoms-statistics-and-treatment.html) - PrimeHealthChannel

Fetal Alcohol Spectrum Disorders (FASD) describes a continuum of permanent birth defects caused by maternal
consumption of alcohol during pregnancy, which includes, but is not limited to fetal alcohol syndrome (FAS).[1] [2]
Approximately 1 percent of children are believed to suffer from fetal alcohol spectrum disorder.[3]
Over time, as it became apparent through research and clinical experience that a range of effects (including physical,
behavioral, and cognitive) could arise from prenatal alcohol exposure, the term Fetal Alcohol Spectrum Disorders, or
FASD, was developed to include Fetal alcohol syndrome (FAS) as well as other conditions resulting from prenatal
alcohol exposure.[4] There are a number of other subtypes with evolving nomenclature and definitions based on
partial expressions of FAS, including Partial Fetal Alcohol Syndrome (PFAS), Alcohol-Related
Neurodevelopmental Disorder (ARND), Alcohol-Related Birth Defects (ARBD), and Fetal Alcohol Effect
(FAE).
The term Fetal Alcohol Spectrum Disorders is not in itself a clinical diagnosis but describes the full range of
disabilities that may result from prenatal alcohol exposure. Currently, Fetal Alcohol Syndrome (FAS)[5] [6] [7] is the
only expression of prenatal alcohol exposure that is defined by the International Statistical Classification of Diseases
and Related Health Problems and assigned ICD-9 and ICD-10 diagnoses.
There is no known safe amount of alcohol or safe time to drink alcohol during pregnancy. Because of this, the
current recommendation of both the Surgeon General of the United States and the British Department of Health is to
drink no alcohol at all if one is pregnant or planning to become pregnant.
307
Diagnostic systems
The original syndrome of Fetal Alcohol Syndrome (FAS) was reported in 1973, four FASD diagnostic systems that
diagnose FAS and other FASD conditions have been developed in North America:
The Institute of Medicine's guidelines for FAS, the first system to standardize diagnoses of individuals with
prenatal alcohol exposure,[7]
The University of Washington's "The 4-Digit Diagnostic Code," which ranks the four key features of FASD on a
Likert scale of one to four and yields 256 descriptive codes that can be categorized into 22 distinct clinical
categories, ranging from FAS to no findings,[1]
The Centers for Disease Control's "Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis," which
established consensus on the diagnosis FAS in the U.S. but deferred addressing other FASD conditions,[8] and
Canadian guidelines for FASD diagnoses, which established criteria for diagnosing FASD in Canada and
harmonized most differences between the IOM and University of Washington's systems.[9]
Each diagnostic system requires that a complete FASD evaluation include assessment of the four key features of
FASD, described below. A positive finding on all four features is required for a diagnosis of FAS, the first
diagnosable condition of FASD that was discovered. However, prenatal alcohol exposure and central nervous system
damage are the critical elements of the spectrum of FASD, and a positive finding in these two features is
sufficamanient for an FASD diagnosis that is not "full-blown FAS." Diagnoses are described in a following section.
Epidemiology
Approximately 1 percent of children are affected by fetal alcohol spectrum disorder; the majority of these children
fail to receive a proper diagnosis of fetal alcohol spectrum disorder. One study found that 6 out of 7 first grade age
children failed to receive a diagnosis and another study found that of 40 new born babies with obvious fetal alcohol
syndrome 100 percent left the hospital without a diagnosis.[3]
Key features of FASD

Each of the key features of FASD can vary widely within one individual exposed to prenatal alcohol. While
consensus exists for the definition and diagnosis of FAS across diagnostic systems, minor variations among the
systems lead to differences in definitions and diagnostic cut-off criteria for other disgnoses across the FASD
continuum. (The central nervous system (CNS) damage criteria particularly lack clear consensus.) A working
knowledge of the key features is helpful in understanding FASD diagnoses and conditions, and each are reviewed
with attention to similarities and differences across the four diagnostic systems.
Growth deficiency
In terms of FASD, growth deficiency is defined as significantly below average height, weight or both due to prenatal
alcohol exposure, and can be assessed at any point in the lifespan. Growth measurements must be adjusted for
parental height, gestational age (for a premature infant), and other postnatal insults (e.g., poor nutrition), although
birth height and weight are the preferred measurements.[1] Deficiencies are documented when height or weight falls
at or below the 10th percentile of standardized growth charts appropriate to the patient's population.[10]
Criteria for FASD are least specific in the IOM diagnostic system ("low birth weight..., decelerating weight not due
to nutrition..., [or] disproportional low weight to height" p.4 of executive summary),[7] while the CDC and Canadian
guidelines use the 10th percentile as a cut-off to determine growth deficiency.[8] [9] The "4-Digit Diagnostic Code"
allows for mid-range gradations in growth deficiency (between the 3rd and 10th percentiles) and severe growth
deficiency at or below the 3rd percentile.[1] Growth deficiency (at severe, moderate, or mild levels) contributes to
diagnoses of FAS and PFAS, but not ARND or static encephalopathy.
Growth deficiency is ranked as follows by the "4-Digit Diagnostic Code:"[1]
308
Severe Height and weight at or below the 3rd percentile.

Moderate Either height or weight at or below the 3rd percentile, but not both.
Mild Either height or weight or both between the 3rd and 10th percentiles.
None Height and weight both above the 10th percentile.
In the initial studies that discovered FAS, growth deficiency was a requirement for inclusion in the studies; thus, all
the original patients with FAS had growth deficiency as an artifact of sampling characteristics used to establish
criteria for the syndrome. That is, growth deficiency is a key feature of FASD because growth deficiency was a
criterion for inclusion in the original study that determined the definition of FAS. This reinforces assertions that
growth deficiency and FAS facial features are less critical for understanding the disability's of FASD than the
neurobehavioral sequelae to the brain damage.[7]
FAS facial features

Several characteristic craniofacial abnormalities are visible in individuals with FAS,[11] but these may be mild or
even non-existent in other FASD conditions.[1]
Refinements in diagnostic criteria since 1975 have yielded three distinctive and diagnostically significant facial
features known to result from prenatal alcohol exposure and distinguishes FAS from other disorders with partially
overlapping characteristics.[12] [13] The three FAS facial features are:
A smooth philtrum The divot or groove between the nose and upper lip flattens with increased prenatal alcohol
exposure.
Thin vermilion The upper lip thins with increased prenatal alcohol exposure.
Small palpebral fissures Eye-width shortens with increased prenatal alcohol exposure.
Measurement of FAS facial features uses criteria developed by the University of Washington. The lip and philtrum
are measured by a trained physician with the Lip-Philtrum Guide,[14] a 5-point Likert Scale with representative
photographs of lip and philtrum combinations ranging from normal (ranked 1) to severe (ranked 5). Palpebral fissure
length (PFL) is measured in millimeters with either calipers or a clear ruler and then compared to a PFL growth
chart, also developed by the University of Washington.[15]
All four diagnostic systems have agreed upon this method for determining FAS facial feature severity rankings.
Ranking FAS facial features is complicated because the three separate facial features can be affected independently
by prenatal alcohol.[1] [16]
Central nervous system damage

Central nervous system (CNS) damage is the primary key feature of any FASD diagnosis. Prenatal alcohol exposure,
a teratogen, can damage the brain across a continuum of gross to subtle impairments, depending on the amount,
timing, and frequency of the exposure as well as genetic predispositions of the fetus and mother.[7] [17] While
functional abnormalities are the behavioral and cognitive expressions of the FASD disability, CNS damage can be
assessed in three areas: structural, neurological, and functional impairments.
All four diagnostic systems allow for assessment of CNS damage in these areas, but criteria vary. The IOM system
requires structural or neurological impairment for a diagnosis of FAS, but also allows a "complex pattern" of
functional anomalies for diagnosing PFAS and ARND.[7] The "4-Digit Diagnostic Code" and CDC guidelines allow
for a positive CNS finding in any of the three areas for any FASD diagnosis, but functional anomalies must measure
at two standard deviations or worse in three or more functional domains for a diagnoses of FAS, PFAS, and
ARND.[1] [8] The "4-Digit Diagnostic Code" also allows for an FASD diagnosis when only two functional domains
are measured at two standard deviations or worse.[1] The "4-Digit Diagnostic Code" further elaborates the degree of
CNS damage according to four ranks:
Definite Structural impairments or neurological impairments for FAS or static encephalopathy.
309

Probable Significant dysfunction of two standard deviations or worse in three or more functional domains.
Possible Mild to moderate dysfunction of two standard deviations or worse in one or two functional domains or
by judgment of the clinical evaluation team that CNS damage cannot be dismissed.
Unlikely No evidence of CNS damage.
Structural
Structural abnormalities of the brain are observable, physical damage to the brain or brain structures caused by
prenatal alcohol exposure. Structural impairments may include microcephaly (small head size) of two or more
standard deviations below the average, or other abnormalities in brain structure (e.g., agenesis of the corpus
callosum, cerebellar hypoplasia).[7]
Microcephaly is determined by comparing head circumference (often called occipitofrontal circumference, or OFC)
to appropriate OFC growth charts.[10] Other structural impairments must be observed through medical imaging
techniques by a trained physician. Because imaging procedures are expensive and relatively inaccessible to most
patients, diagnosis of FASD is not frequently made via structural impairments except for microcephaly.
Neurological
When structural impairments are not observable or do not exist, neurological impairments are assessed. In the
context of FASD, neurological impairments are caused by prenatal alcohol exposure which causes general
neurological damage to the central nervous system (CNS), the peripheral nervous system, or the autonomic nervous
system. A determination of a neurological problem must be made by a trained physician, and must not be due to a
postnatal insult, such as a high fever, concussion, traumatic brain injury, etc.
All four diagnostic systems show virtual agreement on their criteria for CNS damage at the neurological level, and
evidence of a CNS neurological impairment due to prenatal alcohol exposure will result in a diagnosis of FAS or
PFAS, and functional impairments are highly likely.[1] [7] [8] [9]
Neurological problems are expressed as either hard signs, or diagnosable disorders, such as epilepsy or other seizure
disorders, or soft signs. Soft signs are broader, nonspecific neurological impairments, or symptoms, such as impaired
fine motor skills, neurosensory hearing loss, poor gait, clumsiness, poor eyehand coordination, or sensory
integration dysfunction. Many soft signs have norm-referenced criteria, while others are determined through clinical
judgment.
Functional
When structural or neurological impairments are not observed, all four diagnostic systems allow CNS damage due to
prenatal alcohol exposure to be assessed in terms of functional impairments.[1] [7] [8] [9] Functional impairments are
deficits, problems, delays, or abnormalities due to prenatal alcohol exposure (rather than hereditary causes or
postnatal insults) in observable and measurable domains related to daily functioning, often referred to as
developmental disabilities. There is no consensus on a specific pattern of functional impairments due to prenatal
alcohol exposure[7] and only CDC guidelines label developmental delays as such,[8] so criteria (and FASD
diagnoses) vary somewhat across diagnostic systems.
The four diagnostic systems list various CNS domains that can qualify for functional impairment that can determine
an FASD diagnosis:
Evidence of a complex pattern of behavior or cognitive abnormalities inconsistent with developmental level in the
following CNS domains Sufficient for a PFAS or ARND diagnosis using IOM guidelines[7]
Learning disabilities, academic achievement, impulse control, social perception, communication, abstraction,
math skills, memory, attention, judgment
domains Sufficient for an FAS, PFAS or static encephalopathy diagnosis using 4-Digit Diagnostic Code[1]
310

Executive functioning, memory, cognition, social/adaptive skills, academic achievement, language, motor
skills, attention, activity level
General cognitive deficits (e.g., IQ) at or below the 3rd percentile on standardized testing Sufficient for an FAS
diagnosis using CDC guidelines[8]
Performance at or below the 16th percentile on standardized testing in three or more of the following CNS
domains Sufficient for an FAS diagnosis using CDC guidelines[8]
Cognition, executive functioning, motor functioning, attention and hyperactive problems, social skills, sensory
integration dysfunction, social communication, memory, difficulties responding to common parenting practices
domains Sufficient for an FAS diagnosis using Canadian guidelines
Cognition, communication, academic achievement, memory, executive functioning, adaptive behavior, social
skills, social communication
Ten Brain Domains
A recent effort to standardize assessment of functional CNS damage has been suggested by an experienced FASD
diagnostic team in Minnesota.[18] The proposed framework attempts to harmonize IOM, 4-Digit Diagnostic Code,
CDC, and Canadian guidelines for measuring CNS damage viz-a-viz FASD evaluations and diagnosis. The
standardized approach is referred to as the Ten Brain Domains and encompasses aspects of all four diagnostic
systems' recommendations for assessing CNS damage due to prenatal alcohol exposure. The framework provides
clear definitions of brain dysfunction, specifies empirical data needed for accurate diagnosis, and defines
intervention considerations that address the complex nature of FASD with the intention to avoid common secondary
disabilities.[19]
The proposed Ten Brain Domains include:[19]
Achievement, adaptive behavior, attention, cognition, executive functioning, language, memory, motor skills,
sensory integration or soft neurological problems, social communication[19]
The Fetal Alcohol Diagnostic Program (FADP)[18] uses unpublished Minnesota state criteria of performance at 1.5
or more standard deviations on standardized testing in three or more of the Ten Brain Domains to determine CNS
damage. However, the Ten Brain Domains are easily incorporated into any of the four diagnostic systems' CNS
damage criteria, as the framework only proposes the domains, rather than the cut-off criteria for FASD.
Prenatal alcohol exposure

Prenatal alcohol exposure is determined by interview of the biological mother or other family members
knowledgeable of the mother's alcohol use during the pregnancy (if available), prenatal health records (if available),
and review of available birth records, court records (if applicable), chemical dependency treatment records (if
applicable), or other reliable sources.
Exposure level is assessed as Confirmed Exposure, Unknown Exposure, and Confirmed Absence of Exposure
by the IOM, CDC and Canadian diagnostic systems. The "4-Digit Diagnostic Code" further distinguishes confirmed
exposure as High Risk and Some Risk:
High Risk Confirmed use of alcohol during pregnancy known to be at high blood alcohol levels (100mg/dL or
greater) delivered at least weekly in early pregnancy.
Some Risk Confirmed use of alcohol during pregnancy with use less than High Risk or unknown usage
patterns.
Unknown Risk Unknown use of alcohol during pregnancy.
No Risk Confirmed absence of prenatal alcohol exposure.
311

Confirmed exposure
Amount, frequency, and timing of prenatal alcohol use can dramatically impact the other three key features of
FASD. While consensus exists that alcohol is a teratogen, there is no clear consensus as to what level of exposure is
toxic.[7] The CDC guidelines are silent on these elements diagnostically. The IOM and Canadian guidelines explore
this further, acknowledging the importance of significant alcohol exposure from regular or heavy episodic alcohol
consumption in determining, but offer no standard for diagnosis. Canadian guidelines discuss this lack of clarity and
parenthetically point out that "heavy alcohol use" is defined by the National Institute on Alcohol Abuse and
Alcoholism as five or more drinks per episode on five or more days during a 30 day period.[20]
"The 4-Digit Diagnostic Code" ranking system distinguishes between levels of prenatal alcohol exposure as High
Risk and Some Risk. It operationalizes high risk exposure as a blood alcohol concentration (BAC) greater than
100mg/dL delivered at least weekly in early pregnancy. This BAC level is typically reached by a 55kg female
drinking six to eight beers in one sitting.[1]
Unknown exposure
For many adopted or adult patients and children in foster care, records or other reliable sources may not be available
for review. Reporting alcohol use during pregnancy can also be stigmatizing to birth mothers, especially if alcohol
use is ongoing.[8] In these cases, all diagnostic systems use an unknown prenatal alcohol exposure designation. A
diagnosis of FAS is still possible with an unknown exposure level if other key features of FASD are present at
clinical levels.
Confirmed absence of exposure
Confirmed absence of exposure would apply to planned pregnancies in which no alcohol was used or pregnancies of
women who do not use alcohol or report no use during the pregnancy. This designation is relatively rare, as most
patients presenting for an FASD evaluation are at least suspected to have had a prenatal alcohol exposure due to
presence of other key features of FASD.[1] [8]
Diagnosis
While the four diagnostic systems essentially agree on criteria for Fetal Alcohol Syndrome (FAS), there are still
differences when full criteria for FAS are not met. This has resulted in differing and evolving nomenclature for other
conditions across the spectrum of FASD, which may account for such a wide variety of terminology. Most
individuals with deficits resulting from prenatal alcohol exposure do not express all features of FAS and fall into
other FASD conditions.[7] The Canadian guidelines recommend the assessment and descriptive approach of the
"4-Digit Diagnostic Code" for each key feature of FASD and the terminology of the IOM in diagnostic categories,
excepting ARBD.[9]
Fetal Alcohol Syndrome or FAS is the only expression of FASD that has garnered consensus among experts to
become an official ICD-9 and ICD-10 diagnosis. To make this diagnosis or determine any FASD condition, a
multi-disciplinary evaluation is necessary to assess each of the four key features for assessment. Generally, a trained
physician will determine growth deficiency and FAS facial features. While a qualified physician may also assess
central nervous system structural abnormalities and/or neurological problems, usually central nervous system
damage is determined through psychological, speech-language, and occupational therapy assessments to ascertain
clinically significant impairments in three or more of the Ten Brain Domains.[19] Prenatal alcohol exposure risk may
be assessed by a qualified physician, psychologist, social worker, or chemical health counselor. These professionals
work together as a team to assess and interpret data of each key feature for assessment and develop an integrative,
multi-disciplinary report to diagnose FAS (or other FASD conditions) in an individual.
312
Other FASD diagnoses

Other FASD conditions are partial expressions of FAS, and here the terminology shows less consensus across
diagnostic systems, which has led to some confusion for clinicians and patients. A key point to remember is that
other FASD conditions may create disabilities similar to FAS if the key area of central nervous system damage
shows clinical deficits in two or more of the Ten Brain Domains. Essentially, growth deficiency and/or FAS facial
features may be mild or nonexistent in other FASD conditions, but clinically significant brain damage of the central
nervous system is present. In these other FASD conditions, an individual may be at greater risk for adverse outcomes
because brain damage is present without associated visual cues of poor growth or the "FAS face" that might
ordinarily trigger an FASD evaluation. Such individuals may be misdiagnosed with primary mental health disorders
such as ADHD or Oppositional Defiance Disorder without appreciation that brain damage is the underlying cause of
these disorders, which requires a different treatment paradigm than typical mental health disorders. While other
FASD conditions may not yet be included as an ICD or DSM-IV-TR diagnosis, they nonetheless pose significant
impairment in functional behavior because of underlying brain damage.
Partial FAS (PFAS)
Previously known as Atypical FAS in the 1997 edition of the "4-Digit Diagnostic Code," patients with Partial Fetal
Alcohol Syndrome have a confirmed history of prenatal alcohol exposure, but may lack growth deficiency or the
complete facial stigmata. Central nervous system damage is present at the same level as FAS. These individuals have
the same functional disabilities but "look" less like FAS.
The following criteria must be fully met for a diagnosis of Partial FAS:[1] [7] [9]
1. Growth deficiency Growth or height may range from normal to deficient[10]
2. FAS facial features Two or three FAS facial features present[15]
3. Central nervous system damage Clinically significant structural, neurological, or functional impairment in three
or more of the Ten Brain Domains[19]
4. Prenatal alcohol exposure Confirmed prenatal alcohol exposure
Alcohol-Related Neurodevelopmental Disorder (ARND)
Alcohol-Related Neurodevelopmental Disorder (ARND) was initially suggested by the Institute of Medicine to
replace the term FAE and focus on central nervous system damage, rather than growth deficiency or FAS facial
features. The Canadian guidelines also use this diagnosis and the same criteria. While the "4-Digit Diagnostic Code"
includes these criteria for three of its diagnostic categories, it refers to this condition as static encephalopathy. The
behavioral effects of ARND are not necessarily unique to alcohol however, so use of the term must be within the
context of confirmed prenatal alcohol exposure.[21] ARND may be gaining acceptance over the terms FAE and
ARBD to describe FASD conditions with central nervous system abnormalities or behavioral or cognitive
abnormalities or both due to prenatal alcohol exposure without regard to growth deficiency or FAS facial
features.[21] [22]
The following criteria must be fully met for a diagnosis of ARND or static encephalopathy:[1] [7] [9]
1. Growth deficiency Growth or height may range from normal to minimally deficient[10]
2. FAS facial features Minimal or no FAS facial features present[15]
3. Central nervous system damage Clinically significant structural, neurological, or functional impairment in three
or more of the Ten Brain Domains[19]
4. Prenatal alcohol exposure Confirmed prenatal alcohol exposure
313

Fetal Alcohol Effects (FAE)
This term was initially used in research studies to describe humans and animals in whom teratogenic effects were
seen after confirmed prenatal alcohol exposure (or unknown exposure for humans), but without obvious physical
anomalies.[6] Smith (1981) described FAE as an "extremely important concept" to highlight the debilitating effects
of brain damage, regardless of the growth or facial features.[23] This term has fallen out of favor with clinicians
because it was often regarded by the public as a less severe disability than FAS, when in fact its effects can be just as
detrimental.[24]
Alcohol-Related Birth Defects (ARBD)
Formerly known as Possible Fetal Alcohol Effect (PFAE),[6] Alcohol-Related Birth Defects (ARBD) was a term
proposed as an alternative to FAE and PFAE[25] The IOM presents ARBD as a list of congenital anomalies that are
linked to maternal alcohol use but have no key features of FASD.[7] PFAE and ARBD have fallen out of favor
because these anomalies are not necessarily specific to maternal alcohol consumption and are not criteria for
diagnosis of FASD.[21] The Canadian guidelines recommend that ARBD should not be used as an umbrella term or
diagnostic category for FASD
References
[1] Astley, S.J. (2004). Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code. Seattle: University of
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Retrieved on 2007-04-11
[2] Ratey, J.J. (2001). A User's Guide to the Brain: Perception, Attention, and the Four Theaters of the Brain. New York: Vintage Books. ISBN
0-375-70107-9.
[3] May, PA.; Gossage, JP. (2001). "Estimating the prevalence of fetal alcohol syndrome. A summary." (http:/ / pubs. niaaa. nih. gov/
publications/ arh25-3/ 159-167. htm). Alcohol Res Health 25 (3): 15967. PMID11810953. .
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Discovers the Tragic Toll of Alcohol in Pregnancy. New York: Carroll & Graf. ISBN 0-7867-1550-2.
[5] Jones K.L., Smith D.W, Ulleland C.N., Streissguth A.P. (1973). "Pattern of malformation in offspring of chronic alcoholic mothers". Lancet 1
(7815): 12671271. doi:10.1016/S0140-6736(73)91291-9. PMID4126070.
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Prevention, and Treatment. Washington, DC: National Academy Press. ISBN 0309052920
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FAS_guidelines_accessible. pdf) CDC (July 2004). Retrieved on 2009-09-22
[9] Chudley A, Conry J, Cook J, et al. (2005). "Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis" (http:/ / www. cmaj. ca/ cgi/
content/ full/ 172/ 5_suppl/ S1). CMAJ 172 (5 Suppl): S1S21. doi:10.1503/cmaj.1040302. PMC557121. PMID15738468. . Retrieved
2007-04-10.
[10] Clinical growth charts. (http:/ / www. cdc. gov/ nchs/ about/ major/ nhanes/ growthcharts/ clinical_charts. htm#Clin 2) National Center for
Growth Statistics. Retrieved on 2007-04-10
[11] Jones K.L., Smith D.W. (1975). "The fetal alcohol syndrome". Teratology 12 (1): 110. doi:10.1002/tera.1420120102. PMID1162620.
[12] Astley S.J., Clarren S.K. (1996). "A case definition and photographic screening tool for the facial phenotype of fetal alcohol syndrome".
Journal of Pediatrics 129 (1): 3341. doi:10.1016/S0022-3476(96)70187-7. PMID8757560.
[13] Astley S.J., Stachowiak J., Clarren S.K., Clausen C. (2002). "Application of the fetal alcohol syndrome facial photographic screening tool in
a foster care population". Journal of Pediatrics 141 (5): 712717. doi:10.1067/mpd.2002.129030. PMID12410204.
[14] Lip-philtrum guides. (http:/ / depts. washington. edu/ fasdpn/ htmls/ lip-philtrum-guides. htm) FAS Diagnostic and Prevention Network,
University of Washington. Retrieved on 2007-04-10
[15] FAS facial features. (http:/ / depts. washington. edu/ fasdpn/ htmls/ fas-face. htm) FAS Diagnostic and Prevention Network, University of
Washington. Retrieved on 2007-04-10
[16] Astley, Susan. Backside of Lip-Philtrum Guides (2004) (PDF). (http:/ / depts. washington. edu/ fasdpn/ pdfs/ lipguides2004-backside. pdf)
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[17] West, J.R. (Ed.) (1986). Alcohol and Brain Development. New York: Oxford University Press.
[18] FADP Fetal Alcohol Diagnostic Program (http:/ / www. fadpmn. org)
[19] Lang, J. (2006). Ten Brain Domains: A Proposal for Functional Central Nervous System Parameters for Fetal Alcohol Spectrum Disorder
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[20] U.S. Department of Health and Human Services. (2000). National Institute on Alcohol Abuse and Alcoholism. Tenth special report to the
U.S> Congress on alcohol and health: Highlights frfom current research. Washington, DC: The Institute.
[21] Streissguth, A. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Brookes Publishing. ISBN
1-55766-283-5.
[22] Malbin, D. (2002). Fetal Alcohol Spectrum Disorders: Trying Differently Rather Than Harder. Portland, OR: FASCETS, Inc. ISBN
0-9729532-0-5.
[23] Smith D.W. (1981). "Fetal alcohol syndrome and fetal alcohol effects". Neurobehavioral Toxicology and Teratology 3: 127.
[24] Aase J.M., Jones K.L., Clarren S.K. (1995). "Do we need the term FAE?". Pediatrics 95 (3): 428430. PMID7862486.
[25] Sokol R.J., Clarren S.K. (1989). "Guidelines for use of terminology describing the impact of prenatal alcohol on the offspring". Alcoholism:
Clinical and Experimental Research 13 (4): 597598. doi:10.1111/j.1530-0277.1989.tb00384.x.
External links
Center for Disease Control's page on Fetal Alcohol Spectrum Disorders (FASDs) (http://www.cdc.gov/ncbddd/
fasd/index.html)
The FASD Trust (http://www.fasdtrust.co.uk)
Whitecrow Village FASD Society (http://www.whitecrowvillage.org)
SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence (http://fasdcenter.samhsa.gov)
U.S. Congressional Caucus on FASD (http://www.house.gov/pallone/fasd_caucus/welcome.shtml)
NOFAS-UK (http://www.nofas-uk.org)
FASawareUK (http://www.fasaware.co.uk)

Prenatal cocaine exposure (PCE) occurs when a pregnant woman uses cocaine and thereby exposes her fetus to the
drug. Crack baby was a term coined to describe children who were exposed to crack (cocaine in smokable form) as
fetuses; the concept of the crack baby emerged in the US during the 1980s and 90s in the midst of a great deal of
media surrounding crack.[1] Early studies reported that people who had been exposed to crack in utero would be
severely emotionally, mentally, and physically disabled; this belief became common in the scientific and lay
communities.[1] Fears were widespread that a generation of crack babies were going to put severe strain on society
and social services as they grew up. Later studies failed to substantiate the findings of earlier ones that PCE has
severe disabling consequences; these earlier studies had been methodologically flawed (e.g. with small sample sizes
and confounding factors). Scientists have come to understand that the findings of the early studies were vastly
overstated and that most people who were exposed to cocaine in utero are normal.[1]
No specific disorders or conditions have been found to result for people whose mothers used cocaine while
pregnant.[2] Studies focusing on children of six years and younger have not shown any direct, long-term effects of
PCE on language, growth, or development as measured by test scores.[3] PCE also appears to have little effect on
infant growth.[4] However, PCE is associated with premature birth, birth defects, attention deficit disorder, and other
conditions. Cognitive, motor, behavior, developmental, and language problems also appear to result from PCE. The
effects of cocaine on a fetus are thought to be similar to those of tobacco and less severe than those of alcohol.[5] No
scientific evidence has shown a difference in harm to a fetus of crack and powder cocaine.[6]
PCE is very difficult to study because it very rarely occurs in isolation: usually it coexists with a variety of other
factors, which may confound a study's results.[3] For example, pregnant mothers who use cocaine often use other
drugs in addition to cocaine, or they may be malnourished and lacking in medical care. Children in households
where cocaine is abused are at risk of violence and neglect, and those in foster care may experience problems due to
unstable family situations. Thus researchers have had difficulty in determining which effects result from PCE and
which result from other factors in the children's histories.
315
Historical context
During the crack epidemic of the 1980s and 90s in the US, fear existed throughout the country that PCE would create
a generation of youth with severe behavioral and cognitive problems.[7] Early studies in the mid-1980s reported that
cocaine use in pregnancy caused children to have severe problems including cognitive, developmental, and
emotional disruption.[8] These early studies had methodological problems including small sample size, confounding
factors like poor nutrition, and use of other drugs by the mothers.[8] However, the results of the studies sparked
widespread media discussion in the context of the new War on Drugs.[9] For example a 1985 study that showed
harmful effects of cocaine use during pregnancy created a huge media buzz.[8] [10] The term "crack baby" resulted
from the publicity surrounding crack and PCE.[11]
It was common in media reports of the phenomenon to emphasize that babies exposed to crack in utero would never
develop normally.[11] The children were reported to be inevitably destined to be physically and mentally disabled for
their whole lives.[1] Babies exposed to crack in utero were written off as doomed to be severely disabled, and many
were abandoned in hospitals.[12] Experts foresaw the development of a "biological underclass" of born criminals who
would prey on the rest of the population.[10] [12] Crime rates were predicted to rise when the generation of
crack-exposed infants grew up (instead they dropped).[12] It was predicted that the children would be difficult to
console, irritable, and hyperactive, putting a strain on the school system.[4] Charles Krauthammer, a columnist from
The Washington Post wrote in 1989, "[t]heirs will be a life of certain suffering, of probable deviance, of permanent
inferiority."[10] [12] The president of Boston University at the time, John Silber, said "crack babies ... won't ever
achieve the intellectual development to have consciousness of God."[12]
At the time, the proposed mechanism by which cocaine harmed fetuses was as a stimulantit was predicted that
cocaine would disrupt normal development of parts of the brain that dealt with stimulation, resulting in problems like
bipolar disorder and attention deficit disorder.[1] Reports from the mid 1980s to early 90s raised concerns about links
between PCE and slowed growth, deformed limbs, defects of the kidneys and genitourinary and gastrointestinal
tracts, neurological damage, small head size, atrophy or cysts in the cerebral cortex, bleeding into the brain's
ventricles, obstruction of blood supply in the central nervous system.[13] Studies that find that exposure has
significant effects may be more likely to be published than those that do not, a factor that may have biased reporting
on the effects of PCE toward indicating more severe outcomes as the crack epidemic emerged.[13] Between 1980 and
1989, 57% of studies showing cocaine has effects on a fetus were accepted by the Society for Pediatric Research,
compared with only 11% of studies showing no cocaine effects.[14]
After the early studies which reported that PCE children would be severely disabled came studies that purported to
show that cocaine exposure in utero has no important effects.[12] Almost every prenatal complication originally
thought to be due directly to PCE was found to result from confounding factors such as poor maternal nutrition, use
of other drugs, depression, and lack of prenatal care.[15] More recently the scientific community has begun to reach
an understanding that PCE does have some important effects but that they are not severe as was predicted in the
early studies.[12] Most people who were exposed to cocaine in utero are normal.[1] The effects of PCE are subtle but
they exist.[13] [16] [17]
316
Pathophysiology
Cocaine, a small molecule, is able to cross the placenta into the
bloodstream of the fetus.[18] In fact it may be present in a higher
concentration in the amniotic fluid than it is in the mother's
bloodstream.[19] The skin of the fetus is able to absorb the chemical
directly from the amniotic fluid until the 24th week of pregnancy.[19]
Cocaine can also show up in breast milk and affect the nursing
baby.[19] [20]
Cocaine prevents the reuptake of neurotransmitters such as
Cocaine is a small enough molecule to pass
across
the placental barrier into the bloodstream
norepinepherine and epinepherine, so they stay in the synapse longer,
[18]
of the fetus.
causing excitement of the sympathetic nervous system and evoking a
stress response.[14] The euphoria experienced by cocaine users is
thought to be largely due to the way it prevents the neurotransmitter serotonin from being reabsorbed by the
presynaptic neuron which released it.[18]
Use of cocaine during pregnancy can negatively affect both the mother and the fetus.[14] But the ways in which
cocaine affects a fetus are poorly understood.[15] There are multiple mechanisms by which cocaine exposure harms a
fetus: it causes constriction (narrowing) of blood vessels and changes in brain chemistry, and it may alter expression
of certain genes.[21] Cocaine affects neurotransmitters that are involved in the development of the fetus's brain.[22]
Cocaine may affect fetal development directly by altering the development of the monoaminergic system in the
brain.[23] In studies with rats, cocaine has been shown to cause apoptosis (programmed cell death) in fetuses; this
could be a mechanism for some of the abnormalities of the heart associated with PCE.[18]
The ways in which cocaine affects a fetus are poorly understood, but one possibility is that it harms the fetus in part
by interfering with blood supply to the uterus.[19] [24] The reduction in blood flow to the uterus limits the delivery of
oxygen and nutrients to the fetus.[11] The reduced blood flow to the uterus may also play a role in congenital
malformations and slowed fetal growth.[18] For example, it may be this reduction in blood flow that leads to gut
damage in the infant.[19] Cocaine causes changes in the mother's blood pressure that are thought to be the cause of
strokes in the fetus; one study found that 6% of cocaine-exposed infants had had one or more strokes.[19] Such
prenatal strokes may be the cause of neurological problems found in some cocaine-exposed infants after birth.[4]
Blood vessel contraction can also cause premature labor and birth.[11] Cocaine has also been found to enhance the
contractility of the tissue in the uterus, another factor that has been suggested as a possible mechanism for its
contribution to increased prematurity rates.[24] Increased contractility of the uterus may also be behind the increased
likelihood of placental abruption (the placenta tearing away from the uterine wall) which some findings have linked
with PCE.[14]
Diagnosis
Cocaine use during pregnancy can be discovered by asking the mother, but sometimes women will not admit to
having used drugs; this "maternal interview" method has been found to be less reliable for discovering cocaine use
than for other drugs such as marijuana.[25] More reliable methods for detecting cocaine exposure involve testing the
newborn's hair or meconium (the infant's earliest stool).[25] Hair analysis, however, can give false positives for
cocaine exposure.[25] The mother's urine can also be tested for drugs.[23]
317
318
Effects and prognosis

Drug use in the first trimester is the most harmful to the fetus in terms of neurological and developmental
outcome.[26] The effects of PCE later in a child's life are poorly understood; there is little information about the
effects of in utero cocaine exposure on children over age five.[3] Cocaine exposure in utero may affect the structure
and function of the brain, predisposing children to developmental problems later, or these effects may be explained
by children of crack-using mothers being at higher risk for domestic violence, insensitive parenting, and maternal
depression.[3] Some studies have found PCE-related differences in height and weight while others have not; these
differences are generally gone or small by the time children are school-age.[3] When researchers are able to identify
effects that result from PCE, these effects are typically small.[15]
Some effects of PCE have been demonstrated with high exposures to cocaine but not with low ones.[23]
Studies have found that children exposed to cocaine during fetal
development experience problems with language, behavior,
development, and attention.[27] Some, but not all, PCE children
experience hypertonia (excessive muscle tone), problems with
attention, or delays in brain growth or language.[28] However,
systematic reviews have found that after controlling for other factors
that could be misleading, there is no evidence that fetal crack exposure
causes problems different from those caused by other risk factors to
which those fetuses are exposed.[29]
Prematurely born baby
As many as 1727% of cocaine-using pregnant women deliver

prematurely.[24] There are also data showing that spontaneous abortion
and low birth weight are associated with cocaine use.[10] The increased
risk of placental abruption with cocaine use has been well
documented.[18] Using cocaine while pregnant also heightens the
chances of maternal and fetal vitamin deficiencies, respiratory distress
syndrome for the baby, and infarction of the bowels.[19]
Early reports found that cocaine-exposed babies were at high risk for sudden infant death syndrome.[13] However, by
itself, cocaine exposure during fetal development has not subsequently been identified as a risk factor for the
syndrome.[29]
While newborns who were exposed prenatally to drugs such as barbiturates or heroin frequently have symptoms of
drug withdrawal (neonatal abstinence syndrome), this does not happen with babies exposed to crack in utero; at least,
such symptoms are difficult to separate in the context of other factors such as prematurity or prenatal exposure to
other drugs.[11]
Unlike fetal alcohol syndrome, no set of characteristics has been discovered that results uniquely from cocaine
exposure in utero.[15] Much is still not known about what factors may exist to aid children who were exposed to
cocaine in utero.[15]
Mental, emotional, and behavioral outcomes

Little evidence suggests a link between fetal cocaine exposure and problems with cognitive development.[29] In IQ
studies, cocaine-exposed children score no lower than others, and children exposed to marijuana and alcohol in utero
were at the same level as those who were exposed to those drugs in addition to cocaine.[29] In school-age and
younger children, PCE does not appear in studies to predispose children to poorer intellectual performance.[3]
However, results of studies aiming to measure mental performance have been mixed, with some reporting
measurable deficits in cocaine-exposed babies and others showing no differences between cocaine-exposed and
control groups.[16] Studies of developmental delays have also been mixed.[23]
319
Cocaine causes impaired growth of the fetus's brain, an effect that is most pronounced with high levels of cocaine
and prolonged duration of exposure throughout all three trimesters of pregnancy.[28] Those PCE children who had
slowed brain growth as fetuses are at higher risk for impaired brain growth and motor, language and attention
problems after they are born.[28]
Cognitive and attention skills can be impacted by PCE, possibly due to effects on brain areas such as the prefrontal
cortex.[8] Children whose mothers used cocaine during pregnancy may develop symptoms akin to those of attention
deficit disorder.[8] Language development has also been found in some studies to be impacted by PCE,[28] but
language studies have failed to reliably show a detriment caused by in utero cocaine exposure.[29]
Evidence suggests that in utero cocaine exposure leads to problems with behavior and sustained attention, possibly
by affecting parts of the brain that are vulnerable to toxins during fetal development.[3] The changes in behavior and
attention caused by PCE are measurable by standardized scales;[28] however these behavioral effects seem to be
mild.[8]
Physical outcomes
PCE may interfere with the way the motor system matures.[28] Reports on whether PCE affects motor functioning
are mixed, with some reporting measurable deficits and others reporting none.[16] Some, but not all, studies have
found impairments in development of motor skills in cocaine-exposed babies younger than seven months (but not
older); however, this finding could be attributed to a failure to control for in utero tobacco exposure.[29]
A review of the literature reported that cocaine use causes congenital defects between 15 and 20% of the time;
however another large-scale study found no difference in rates of birth anomalies in PCE and non-PCE infants.[30]
Most PCE-related congenital defects are found in the brain, heart, genitourinary tract, arms and legs.[30]
Abnormalities in the development of the heart both before and after birth have been linked to PCE; the mechanism
by which this occurs is poorly understood.[18] Heart malformations can include a missing ventricle and defects with
the septum of the heart, and can result in potentially deadly congestive heart failure.[18] Cocaine use by pregnant
mothers may directly or indirectly contribute to defects in the formation of the circulatory system and is associated
with abnormalities in development of the aorta.[24] Genital malformations occur at a higher-than-normal rate with
PCE.[30] The liver and lungs are also at higher risk for abnormalities.[18] Cloverleaf skull, a congenital malformation
in which the skull has three lobes, the brain is deformed, and hydrocephalus occurs, is also associated with PCE.[31]
It is not well understood why cocaine exposure is associated with congenital malformations.[18] It has been suggested
that some of these birth defects could be due to cocaine's disruption of blood vessel growth.[30]
Epidemiology
An estimated 0.5 to 3% of pregnant women worldwide use cocaine.[2]
In some parts of North America, the rate of cocaine use by pregnant
women is as much as 1045%.[30] In the US, almost 90% of women
who abuse drugs are of childbearing age.[32] [33] A 1995 survey in the
US found that between 30,000 and 160,000 cases of prenatal exposure
to cocaine occur each year.[34] By one estimate, in the US 100,000
babies are born each year after having been exposed to crack cocaine in
utero.[24] Pregnant women in urban parts of the US and who are of a
low socioeconomic status use cocaine more often.[23] However, the
real prevalence of cocaine use by pregnant women is unknown.[15]
Up to 3% of pregnant women worldwide use

cocaine.
Legal and ethical issues

The harm to a child from PCE has implications for public policy and law. Some US states have pressed charges
against pregnant women who use drugs, including child abuse, homicide, and distribution of drugs to a minor;
however these approaches have generally been rejected in the courts on the basis that a fetus is not legally a child.[26]
Between 1985 and 2001, more than 200 women in over 30 US states faced prosecution for drug use during
pregnancy.[29] In South Carolina, a woman who used crack in her third trimester of pregnancy was sentenced to
prison for eight years when her child was born with cocaine metabolites in its system.[26] The Supreme Court of
South Carolina upheld this conviction.[26] From 1989 to 1994, in the midst of public outcry about cocaine babies, the
Medical University of South Carolina tested pregnant women for cocaine, reporting those who tested positive to the
police.[35] The US Supreme Court found the policy to be unacceptable on constitutional grounds in 2001.[35]
Some advocates argue that punishment for crack-using pregnant women as a means to treat their addiction is a
violation of their right to privacy.[26] According to studies, fear of prosecution and having children taken away is
associated with a refusal to seek prenatal care or medical treatment.[8]
Some nonprofit organizations aim to prevent PCE with birth control. One such initiative, Project Prevention, offers
crack-addicted women money as an incentive to undergo long-term birth control or, frequently, sterilizationan
approach which has brought it under fire for eugenics.[36]
Social stigma
Children who were exposed to crack prenatally face social stigma as babies and school-aged children; some experts
say that the "crack baby" social stigma is more harmful than the PCE.[10] Teachers may expect these children to be
disruptive and developmentally delayed.[29] Children who were exposed to cocaine may be teased by others who
know of the exposure, and problems these children have may be misdiagnosed by doctors or others as resulting from
PCE when they may really be due to factors like illness or abuse.[7]
The social stigma of the drug also complicates studies of PCE; researchers labor under the awareness that their
findings will have political implications.[7] In addition, the perceived hopelessness of 'crack babies' may cause
researchers to ignore possibilities for early intervention that could help them.[4] The social stigma may turn out to be
a self-fulfilling prophecy.[37]
Research
A number of the effects that had been thought after early studies to be attributable to prenatal exposure to cocaine are
actually due partially or wholly to other factors, such as exposure to other substances (including tobacco, alcohol, or
marijuana) or to the environment in which the child is raised.[29] [30] Some effects (such as head circumference, body
weight, and height) that appear in studies to result from prenatal cocaine exposure disappear when studies control for
prenatal exposure to other drugs.[29]
PCE is very difficult to study because of a variety of factors that may confound the results: pre- and postnatal care
may be poor; the pregnant mother and child may be malnourished; the amount of cocaine a mother takes can vary;
she may take a variety of drugs during pregnancy in addition to cocaine; measurements for detecting deficits may not
be sensitive enough; and results that are found may only last a short time.[34] PCE is clustered with other risk factors
to the child such as maltreatment, domestic violence, and prenatal exposure to other substances.[30] Such
environmental factors are known to adversely affect children in the same areas being studied with respect to PCE.[23]
Most women who use cocaine while pregnant use other drugs too.[38] Addiction to any substance, including crack,
may be a risk factor for child abuse or neglect.[29] Crack addiction, like other addictions, distracts parents from the
child and leads to inattentive parenting.[11] Many drug users do not get prenatal care, for a variety of reasons
including that they may not know they are pregnant.[26] Many crack addicts get no medical care at all and have
extremely poor diets, and children who around crack smoking are at risk of inhaling secondary smoke.[11] Cocaine
320

using mothers also have a higher rate of to sexually transmitted infections such as HIV and hepatitis.[13] Drug use by
mothers puts children at high risk for environmental problems, and PCE does not present much risk beyond these
risk factors that occur alongside it.[3] In some cases, it is not clear whether direct results of PCE lead to behavioral
problems, or whether environmental factors are at fault.[3] For examples, it may be that children who have caregiver
instability have more behavioral problems as a result, or it may be that behavioral problems manifested by PCE
children lead to greater turnover in caregivers.[3] Other factors that make studying PCE difficult include high rates of
attrition (loss of participants) from studies, unwillingness of mothers to tell the truth about drug history, and
uncertainty of dosages of street drugs.[23]
The difficulties in isolating crack exposure and other difficulties with studies mean that although many effects
previously thought to have been attributable to crack exposure in utero have not been found, undiscovered effects
may emerge as pressures on children grow as they reach school age and puberty.[29]
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ISBN0-495-50580-3.
Goldberg R (2009). "Cocaine amphetamines". Drugs Across the Spectrum. Pacific Grove: Brooks Cole.
ISBN0-495-55793-5.
Volpe, JJ (2008). "Teratogenic effects of drugs and passive addiction". Neurology of the Newborn. Philadelphia:
Saunders. ISBN1-4160-3995-3.
Yaffe, SJ; Briggs, GG; Freeman, RA (2008). "Cocaine". Drugs in pregnancy and lactation: A reference guide to
fetal and neonatal risk. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
ISBN0-7817-7876-X.
Lewis and Kestler (2011). Gender Differences in Prenatal Substance Exposure. Amer Psychological Society.
ISBN978-1433810336.
Soby, Jeanette M. (2006). Prenatal Exposure to Drugs/Alcohol: Characteristics And Educational Implications of
Fetal Alcohol Syndrome And Cocaine/polydrug Effects. Charles C. Thomas Ltd.. ISBN978-0398076351.
Steinberg, Wenzel, Kosofsky, Harvey, and Iguchi (2001). Prenatal Cocaine Exposure: Scientific Considerations
and Policy Implications. 2001: RAND Drug Policy Research Center and NY Academy of Sciences.
ISBN978-0833030016.
322
323

Child with cleft lip and palate.

[1]
ICD-10
Q35
ICD-9
749
eMedicine
ped/2679
-Q37
[2]
[3]
[4]
Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also occur together as cleft lip and palate, are
variations of a type of clefting congenital deformity caused by abnormal facial development during gestation. A cleft
is a fissure or openinga gap. It is the non-fusion of the body's natural structures that form before birth.
Approximately 1 in 700 children born have a cleft lip and/or a cleft palate. An older term is harelip, based on the
similarity to the cleft in the lip of a hare.
Clefts can also affect other parts of the face, such as the eyes, ears, nose, cheeks, and forehead. In 1976, Paul Tessier
described fifteen lines of cleft. Most of these craniofacial clefts are even more rare and are frequently described as
Tessier clefts using the numerical locator devised by Tessier.[5]
A cleft lip or palate can be successfully treated with surgery, especially so if conducted soon after birth or in early
childhood.
324
Signs and symptoms

If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. Cleft lip is formed in the top
of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose
(complete cleft). Lip cleft can occur as a one sided (unilateral) or two sided (bilateral). It is due to the failure of
fusion of the maxillary and medial nasal processes (formation of the primary palate).
Unilateral incomplete
Unilateral complete
Bilateral complete
A mild form of a cleft lip is a microform cleft.[6] A microform cleft can appear as small as a little dent in the red
part of the lip or look like a scar from the lip up to the nostril.[7] In some cases muscle tissue in the lip underneath the
scar is affected and might require reconstructive surgery.[8] It is advised to have newborn infants with a microform
cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft.[9]
6 month old girl before going into surgery to

have her unilateral complete cleft lip repaired.
The same girl, 1 month after the

surgery.
Same girl, age 8. Note how the scar

is almost gone.
325
Cleft palate
Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not
completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also present. Cleft palate
occurs in about one in 700 live births worldwide.[10]
Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a 'hole' in
the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the uvula is usually split. It occurs due
to the failure of fusion of the lateral palatine processes, the nasal septum, and/or the median palatine processes
(formation of the secondary palate).
The hole in the roof of the mouth caused by a cleft connects the mouth directly to the nasal cavity.
Note: the next images show the roof of the mouth. The top shows the nose, the lips are colored pink. For clarity the
images depict a toothless infant.
Incomplete cleft palate
Unilateral complete lip and palate
Bilateral complete lip and palate
A result of an open connection between the oral cavity and nasal cavity is called velopharyngeal inadequacy (VPI).
Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions
while talking.[11] Secondary effects of VPI include speech articulation errors (e.g., distortions, substitutions, and
omissions) and compensatory misarticulations and mispronunciations (e.g., glottal stops and posterior nasal
fricatives).[12] Possible treatment options include speech therapy, prosthetics, augmentation of the posterior
pharyngeal wall, lengthening of the palate, and surgical procedures.[11]
Submucous cleft palate (SMCP) can also occur, which is a cleft of the soft palate with a classic clinical triad of a
bifid, or split, uvula which is found dangling in the back of the throat, a furrow along the midline of the soft palate,
and a notch in the back margin of the hard palate.[13]
Psychosocial issues
Having a cleft palate/lip does not inevitably lead to a psychosocial problem. Most children who have their clefts
repaired early enough are able to have a happy youth and a healthy social life. However, it is important to remember
that adolescents with cleft palate/lip are at an elevated risk for developing psychosocial problems especially those
relating to self concept, peer relationships, and appearance. It is important for parents to be aware of the psychosocial
challenges their adolescents may face and to know where to find professional help if problems arise.
A cleft palate/lip may impact an individuals self-esteem, social skills, and behavior. There is a large amount of
research dedicated to the psychosocial development of individuals with cleft palate. Self-concept may be adversely
affected by the presence of a cleft lip and or cleft palate, particularly among girls.[14] Research has shown that during
the early preschool years (ages 35), children with cleft lip and or cleft palate tend to have a self-concept that is
similar to their peers without a cleft. However, as they grow older and their social interactions with other children
increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of social
anxiety. Experts conclude that this is probably due to the associated stigma of visible deformities and speech
326
abnormalities, if present. Children who are judged as attractive tend to be perceived as more intelligent, exhibit more
positive social behaviors, and are treated more positively than children with cleft lip and or cleft palate.[15] Children
with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers. Yet these children were
similar to their peers in regard to "how well they liked themselves."
The relationship between parental attitudes and a childs self-concept is crucial during the preschool years. It has
been reported that elevated stress levels in mothers correlated with reduced social skills in their children.[16] Strong
parent support networks may help to prevent the development of negative self-concept in children with cleft
palate.[17] In the later preschool and early elementary years, the development of social skills is no longer only
impacted by parental attitudes but is beginning to be shaped by their peers. A cleft lip and or cleft palate may affect
the behavior of preschoolers. Experts suggest that parents discuss with their children ways to handle negative social
situations related to their cleft lip and or cleft palate. A child who is entering school should learn the proper (and
age-appropriate) terms related to the cleft. The ability to confidently explain the condition to others may limit
feelings of awkwardness and embarrassment and reduce negative social experiences.[18]
As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child
relationship change as peer groups are now the focus of attention. An adolescent with cleft lip and or cleft palate will
deal with the typical challenges faced by most of their peers including issues related to self esteem, dating, and social
acceptance.[19] [20] [21] Adolescents, however, view appearance as the most important characteristic above
intelligence and humor.[22] This being the case, adolescents are susceptible to additional problems because they
cannot hide their facial differences from their peers. Adolescent boys typically deal with issues relating to
withdrawal, attention, thought, and internalizing problems and may possibly develop anxiousness-depression and
aggressive behaviors.[21] Adolescent girls are more likely to develop problems relating to self concept and
appearance. Individuals with cleft lip and or cleft palate often deal with threats to their quality of life for multiple
reasons including: unsuccessful social relationships, deviance in social appearance, and multiple surgeries.
Complications
Cleft may cause problems with feeding, ear disease, speech and
socialization.
Due to lack of suction, an infant with a cleft may have trouble feeding.
An infant with a cleft palate will have greater success feeding in a
more upright position. Gravity will help prevent milk from coming
through the baby's nose if he/she has cleft palate. Gravity feeding can
be accomplished by using specialized equipment, such as the
Haberman Feeder, or by using a combination of nipples and bottle
inserts like the one shown, is commonly used with other infants. A
large hole, crosscut, or slit in the nipple, a protruding nipple and
rhythmically squeezing the bottle insert can result in controllable flow
to the infant without the stigma caused by specialized equipment.
A baby being fed using a customized bottle. The

upright sitting position allows gravity to help the
baby swallow the milk more easily
Individuals with cleft also face many middle ear infections which can
eventually lead to total hearing loss. The Eustachian tubes and external ear canals may be angled or tortuous, leading
to food or other contamination of a part of the body that is normally self cleaning. Hearing is related to learning to
speak. Babies with palatal clefts may have compromised hearing and therefore, if the baby cannot hear, it cannot try
to mimic the sounds of speech. Thus, even before expressive language acquisition, the baby with the cleft palate is at
risk for receptive language acquisition. Because the lips and palate are both used in pronunciation, individuals with
cleft usually need the aid of a speech therapist.
Cause
The development of the face is coordinated by complex morphogenetic events and rapid proliferative expansion, and
is thus highly susceptible to environmental and genetic factors, rationalising the high incidence of facial
malformations. During the first six to eight weeks of pregnancy, the shape of the embryo's head is formed. Five
primitive tissue lobes grow:
a) one from the top of the head down towards the future upper lip; (Frontonasal Prominence)
b-c) two from the cheeks, which meet the first lobe to form the upper lip; (Maxillar Prominence)
d-e) and just below, two additional lobes grow from each side, which form the chin and lower lip; (Mandibular
Prominence)
If these tissues fail to meet, a gap appears where the tissues should have joined (fused). This may happen in any
single joining site, or simultaneously in several or all of them. The resulting birth defect reflects the locations and
severity of individual fusion failures (e.g., from a small lip or palate fissure up to a completely malformed face).
The upper lip is formed earlier than the palate, from the first three lobes named a to c above. Formation of the palate
is the last step in joining the five embryonic facial lobes, and involves the back portions of the lobes b and c. These
back portions are called palatal shelves, which grow towards each other until they fuse in the middle.[23] This
process is very vulnerable to multiple toxic substances, environmental pollutants, and nutritional imbalance. The
biologic mechanisms of mutual recognition of the two cabinets, and the way they are glued together, are quite
complex and obscure despite intensive scientific research.[24]
Genetics
Genetic factors contributing to cleft lip and cleft palate formation have been identified for some syndromic cases, but
knowledge about genetic factors that contribute to the more common isolated cases of cleft lip/palate is still patchy.
Many clefts run in families, even though in some cases there does not seem to be an identifiable syndrome
present,[25] possibly because of the current incomplete genetic understanding of midfacial development.
A number of genes are involved including cleft lip and palate transmembrane protein 1 and GAD1,[26] one of the
glutamate decarboxylases
Syndromes
The Van der Woude Syndrome is caused by a specific variation in the gene IRF6 that increases the occurrence of
these deformities threefold.[27] [28] [29]
Another syndrome, Siderius X-linked mental retardation, is caused by mutations in the PHF8 gene (OMIM
300263 [30]); in addition to cleft lip and/or palate, symptoms include facial dysmorphism and mild mental
retardation.[31]
In some cases, cleft palate is caused by syndromes which also cause other problems.
Stickler's Syndrome can cause cleft lip and palate, joint pain, and myopia.[32] [33]
Loeys-Dietz syndrome can cause cleft palate or bifid uvula, hypertelorism, and aortic aneurysm.[34]
Hardikar syndrome can cause cleft lip and palate, Hydronephrosis, Intestinal obstruction and other symptoms.[35]
Cleft lip/palate may be present in many different chromosome disorders including Patau Syndrome (trisomy 13).
Malpuech facial clefting syndrome
Hearing loss with craniofacial syndromes
Popliteal pterygium syndrome
Treacher Collins Syndrome
Specific genes
Many genes associated with syndromic cases of cleft lip/palate (see above) have been identified to contribute to the
incidence of isolated cases of cleft lip/palate. This includes in particular sequence variants in the genes IRF6, PVRL1
327
328
and MSX1.[36] The understanding of the genetic complexities involved in the morphogenesis of the midface,
including molecular and cellular processes, has been greatly aided by research on animal models, including of the
genes BMP4, SHH, SHOX2, FGF10 and MSX1.[36]
Types include:
Type
OMIM
Gene
Locus
[37]
6p24
[38]
2p13
[39]
19q13
[40]
4q
[41]
MSX1
4p16.1
[42]
1q
[43] PVRL1
11q
OFC1
119530
OFC2
602966
OFC3
600757
OFC4
608371
OFC5
608874
OFC6
608864
OFC7
600644)
OFC8
129400
OFC9
610361
[44]
TP63
3q27
[45]
13q33.1-q34
OFC10 601912 [46]
SUMO1 2q32.2-q33
OFC11 600625 [47]
BMP4
14q22
OFC12 612858 [48]
8q24.3
Environment
Environmental influences may also cause, or interact with genetics to produce, orofacial clefting. An example for
how environmental factors might be linked to genetics comes from research on mutations in the gene PHF8 that
cause cleft lip/palate (see above). It was found that PHF8 encodes for a histone lysine demethylase,[49] and is
involved in epigenetic regulation. The catalytic activity of PHF8 depends on molecular oxygen,[49] a fact considered
important with respect to reports on increased incidence of cleft lip/palate in mice that have been exposed to hypoxia
early during pregnancy.[50] In humans, fetal cleft lip and other congenital abnormalities have also been linked to
maternal hypoxia, as caused by e.g. maternal smoking,[51] maternal alcohol abuse or some forms of maternal
hypertension treatment.[52] Other environmental factors that have been studied include: seasonal causes (such as
pesticide exposure); maternal diet and vitamin intake; retinoids which are members of the vitamin A family;
anticonvulsant drugs; alcohol; cigarette use; nitrate compounds; organic solvents; parental exposure to lead; and
illegal drugs (cocaine, crack cocaine, heroin, etc.).
Current research continues to investigate the extent to which Folic acid can reduce the incidence of clefting.[53]
329
Diagnosis
Traditionally, the diagnosis is made at the time of birth by physical examination. Recent advances in prenatal
diagnosis have allowed obstetricians to diagnose facial clefts in utero.[54]
Treatment
Cleft lip and palate is very treatable; however, the kind of treatment depends on the type and severity of the cleft.
Most children with a form of clefting are monitored by a cleft palate team or craniofacial team through young
adulthood.[55] Care can be lifelong. Treatment procedures can vary between craniofacial teams. For example, some
teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as deciduous teeth
are replaced by permanent teeth, thus saving the child from repeated corrective surgeries), while other teams correct
the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder).
Within teams, treatment can differ between individual cases depending on the type and severity of the cleft.
Cleft lip
Within the first 23 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip
can be performed soon after birth, often the preferred age is at approximately 10 weeks of age, following the "rule of
10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least
10 pounds, and has at least 10g hemoglobin).[56] If the cleft is bilateral and extensive, two surgeries may be required
to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft
lip is the Millard procedure pioneered by Ralph Millard. Millard performed the first procedure at a Mobile Army
Surgical Hospital (MASH) unit in Korea.[57]
Often an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the
group of muscles required to purse the lips run through the upper lip. In order to restore the complete group a full
incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural
lines in the upper lip (such as the edges of the philtrum) and tuck away stitches as far up the nose as possible.
Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip.
The blue lines indicate incisions.
Movement of the flaps; flap A is

moved between B and C. C is
rotated slightly while B is pushed
down.
Pre-operation
Post-operation, the lip is

swollen from surgery
and will get a more
natural look within a
couple of weeks. See
photos in the section
above.

Pre-surgical devices
In some cases of a severe bi-lateral complete cleft, the premaxillary segment will be protruded far outside the mouth.
Nasoalveolar molding prior to surgery can improve long-term nasal symmetry among patients with complete
unilateral cleft lip-cleft palate patients compared to correction by surgery alone, according to a retrospective cohort
study.[58] In this study, significant improvements in nasal symmetry were observed in multiple areas including
measurements of the projected length of the nasal ala (lateral surface of the external nose), position of the
superoinferior alar groove, position of the mediolateral nasal dome, and nasal bridge deviation. "The nasal ala
projection length demonstrated an average ratio of 93.0 percent in the surgery-alone group and 96.5 percent in the
nasoalveolar molding group" this study concluded.
Cleft palate
Often a cleft palate is temporarily closed, the cleft isn't closed, but it is
covered by a palatal obturator (a prosthetic device made to fit the roof
of the mouth covering the gap).
Cleft palate can also be corrected by surgery, usually performed
between 6 and 12 months. Approximately 2025% only require one
palatal surgery to achieve a competent velopharyngeal valve capable of
producing normal, non-hypernasal speech. However, combinations of
surgical methods and repeated surgeries are often necessary as the
child grows. One of the new innovations of cleft lip and cleft palate
A repaired cleft palate on a 64-year-old female.
repair is the Latham appliance.[59] The Latham is surgically inserted by
use of pins during the child's 4th or 5th month. After it is in place, the
doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip and/or palate repair.
If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue.
The bone tissue can be acquired from the patients own chin, rib or hip.
Speech and hearing

A tympanostomy tube is often inserted into the eardrum to aerate the middle ear.[60] This is often beneficial for the
hearing ability of the child.
Children with cleft palate typically have a variety of speech problems. Some speech problems result directly from
anatomical differences such as velopharyngeal inadequacy. Velopharyngeal inadequacy refers to the inability of the
soft palate to close the opening from the throat to the nasal cavity, which is necessary for many speech sounds, such
as /p/, /b/, /t/, /d/, /s/, /z/, etc.[61] This type of errors typically resolve after palate repair.[62]
However, sometimes children with cleft palate also have speech errors which develop as the result of an attempt to
compensate for the inability to produce the target phoneme. These are known as compensatory articulations.
Compensatory articulations are usually sounds that are non-existent in normal English phonology, often do not
resolve automatically after palatal repair, and make a childs speech even more difficult to understand.[62] [63] [64]
Speech-language pathology can be very beneficial to help resolve speech problems associated with cleft palate. In
addition, research has indicated that children who receive early language intervention are less likely to develop
compensatory error patterns later.[65]
330
331
Hearing loss
Hearing impairment is particularly prevalent in children with cleft palate. The tensor muscle fibres that open the
eustachian tubes lack an anchor to function effectively. In this situation, when the air in the middle ear is absorbed
by the mucous membrane, the negative pressure is not compensated, which results in the secretion of fluid into the
middle ear space from the mucous membrane.[66] Children with this problem typically have a conductive hearing
loss primarily caused by this middle ear effusion.[67]
Sample treatment schedule

Note that each individual patient's schedule is treated on a case-by-case basis and can vary per hospital. The table
below shows a common sample treatment schedule. The colored squares indicate the average timeframe in which the
indicated procedure occurs. In some cases this is usually one procedure (for example lip repair) in other cases this is
an ongoing therapy (for example speech therapy).
age
0
m
3
m
6
m
9
m
1
y
2
y
3
y
4
y
5
y
6
y
7
y
8
y
9
y
10
y
11
y
12
y
13
y
14
y
15
y
16
y
17
y
18
y
Palatal obturator
Repair cleft lip
Repair soft palate
Repair hard palate
Tympanostomy tube
Speech therapy/Pharyngoplasty
Bone grafting jaw
Orthodontics
Further cosmetic corrections (Including
jawbone surgery)
Craniofacial team
A craniofacial team is routinely used to treat this condition. The majority of hospitals still use craniofacial teams; yet
others are making a shift towards dedicated cleft lip and palate programs. While craniofacial teams are widely
knowledgeable about all aspects of craniofacial conditions, dedicated cleft lip and palate teams are able to dedicate
many of their efforts to being on the cutting edge of new advances in cleft lip and palate care.
Many of the top pediatric hospitals are developing their own CLP clinics in order to provide patients with
comprehensive multi-disciplinary care from birth through adolescence. Allowing an entire team to care for a child
throughout their cleft lip and palate treatment (which is ongoing) allows for the best outcomes in every aspect of a
child's care. While the individual approach can yield significant results, current trends indicate that team based care
leads to better outcomes for CLP patients. .[68]
332
Epidemiology
Prevalence rates reported for live births for Cleft lip with or without Cleft Palate (CL P) and Cleft Palate alone
(CPO) varies within different ethnic groups.
The highest prevalence rates for (CL P) are reported for Native Americans and Asians. Africans have the lowest
prevalence rates.[69]
Native Americans: 3.74/1000

Japanese: 0.82/1000 to 3.36/1000
Chinese: 1.45/1000 to 4.04/1000
Caucasians: 1.43/1000 to 1.86/1000
Latin Americans: 1.04/1000
Africans: 0.18/1000 to 1.67/1000
Rate of occurrence of CPO is similar for Caucasians, Africans, North American natives, Japanese and Chinese. The
trait is dominant.
Prevalence of "cleft uvula" has varied from .02% to 18.8% with the highest numbers found among Chippewa and
Navajo and the lowest generally in Africans.[70] [71]
Society and culture

Controversy
In some countries, cleft lip or palate deformities are considered reasons (either generally tolerated or officially
sanctioned) to perform abortion beyond the legal fetal age limit, even though the fetus is not in jeopardy of life or
limb. Some human rights activists contend this practice of "cosmetic murder" amounts to eugenics. British
clergywoman Joanna Jepson, who suffered from a congenital jaw deformity herself (not a cleft lip or palate as is
sometimes reported), has started legal action to stop the practice in the United Kingdom[72] [73] (although in the
United Kingdom, such an abortion would not be permitted under the 1967 Abortion Act, because a cleft lip and
palate is not considered a serious handicap).
The Japanese anime Ghost Stories caused controversy through an episode featuring a Kuchisake-onna (a ghost with
a Glasgow smile) because her scar resembled a cleft lip.[74]
Notable cases
Name
Comments
John Henry "Doc"

Holliday
American dentist, gambler and gunfighter of the American Old West, who is usually remembered for his
friendship with Wyatt Earp and the Gunfight at the O.K. Corral
[75]
Tutankhamen
Egyptian pharaoh who may have had a slightly cleft palate according to diagnostic imaging
[76]
Thorgils Skarthi
Thorgils 'the hare-lipped' a 10th century Viking warrior and founder of Scarborough, England.
[77]
Tad Lincoln
Fourth and youngest son of President Abraham Lincoln
[78]
Carmit Bachar
American dancer and singer
[79]
[80]
Jrgen Habermas
German philosopher and sociologist
[81]
Ljubo Milicevic
Australian professional footballer
[82]
Stacy Keach
American actor and narrator
[83]
333
Cheech Marin
American actor and comedian
[84]
Chin-Chin
American magician and stage illusionist
[85]
Owen Schmitt
American football fullback
[86]
Tim Lott
English author and journalist
[87]
Richard Hawley
English musician
[88]
In other animals
Cleft lips and palates are occasionally seen in cattle and dogs, and rarely in sheep, cats, horses, pandas and ferrets.
Most commonly, the defect involves the lip, rhinarium, and premaxilla. Clefts of the hard and soft palate are
sometimes seen with a cleft lip. The cause is usually hereditary. Brachycephalic dogs such as Boxers and Boston
Terriers are most commonly affected.[89] An inherited disorder with incomplete penetrance has also been suggested
in Shih tzus, Swiss Sheepdogs, Bulldogs, and Pointers.[90] In horses, it is a rare condition usually involving the
caudal soft palate.[91] In Charolais cattle, clefts are seen in combination with arthrogryposis, which is inherited as an
autosomal recessive trait. It is also inherited as an autosomal recessive trait in Texel sheep. Other contributing factors
may include maternal nutritional deficiencies, exposure in utero to viral infections, trauma, drugs, or chemicals, or
ingestion of toxins by the mother, such as certain lupines by cattle during the second or third month of gestation.[92]
The use of corticosteroids during pregnancy in dogs and the ingestion of Veratrum californicum by pregnant sheep
have also been associated with cleft formation.[93]
Difficulty with nursing is the most common problem associated with clefts, but aspiration pneumonia, regurgitation,
and malnutrition are often seen with cleft palate and is a common cause of death. Providing nutrition through a
feeding tube is often necessary, but corrective surgery in dogs can be done by the age of twelve weeks.[89] For cleft
palate, there is a high rate of surgical failure resulting in repeated surgeries.[94] Surgical techniques for cleft palate in
dogs include prosthesis, mucosal flaps, and microvascular free flaps.[95] Affected animals should not be bred due to
the hereditary nature of this condition.
Cleft lip in a Boxer
Cleft lip in a Boxer with premaxillary

involvement
Same dog as picture on left, one year later
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[2]
[3]
[4]
[5]
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[6] Kim EK, Khang SK, Lee TJ, Kim TG (May 2010). "Clinical features of the microform cleft lip and the ultrastructural characteristics of the
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[7] Yuzuriha S, Mulliken JB (November 2008). "Minor-form, microform, and mini-microform cleft lip: anatomical features, operative
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PMID18971733. .
[8] Tosun Z, Honuter M, Sentrk S, Savaci N (2003). "Reconstruction of microform cleft lip". Scand J Plast Reconstr Surg Hand Surg 37 (4):
2325. doi:10.1080/02844310310016412. PMID14582757.
[9] Tollefson TT, Humphrey CD, Larrabee WF, Adelson RT, Karimi K, Kriet JD (2011). "The spectrum of isolated congenital nasal deformities
resembling the cleft lip nasal morphology" (http:/ / archfaci. ama-assn. org/ cgi/ pmidlookup?view=long& pmid=21576661). Arch Facial
Plast Surg 13 (3): 15260. doi:10.1001/archfacial.2011.26. PMID21576661. .
[10] "Statistics by country for cleft palate" (http:/ / www. wrongdiagnosis. com/ c/ cleft_palate/ stats-country. htm). WrongDiagnosis.com. .
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External links
Cleft lip and palate Children's Hospital Boston (http://www.childrenshospital.org/az/Site2034/
mainpageS2034P0.html)
Cleft lip and palate and before/after patient photos University of Missouri Children's Hospital (http://
smilesforkids.missouri.edu/common_conditions/clp.php)
Disruption is the term most commonly used for ending an adoption. While technically an adoption is disrupted only
when it is abandoned by the adopting parent or parents before it is legally completed (an adoption that is reversed
after that point is instead referred to in the law as having been dissolved), in practice the term is used for all
adoptions that are ended (more recently, among families disrupting, the euphemism "re-homing" has become
current). It is usually initiated by the parents via a court petition, much like a divorce, to which it is analogous.
While rarely discussed in public, even within the adoption community, the practice has become far more widespread
in recent years, especially among those parents who have adopted from Eastern European countries, particularly
Russia and Romania, where some children have suffered far more from their institutionalization than their parents
were led to believe.
Reasons for disruption

Despite the intense and careful screening that most who wish to adopt children must go through, sometimes the
adoption does not succeed. The child may have developmental or psychological issues that the parents cannot
handle, had not been informed of prior to the adoption, or both. Or the parents may have had unrealistic expectations
of the child, and they just may not get along. The adoptive parents themselves may have psychological or family
issues themselves that led them down the path to adopt. These adoptive parents adopt thinking that the new child in
their life will somehow enhance their life.
Aftermath of disruption
A child who is disrupted is usually put first into foster care, pending placement with a new family, unless they reach
the age of 18 and legally become adults before this happens. In more and more recent disruptions, however, the
disrupting adopters have been in direct contact with a family wishing to adopt and the child can be directly adopted
by the new family.
Some adoption agencies and facilitators have even begun specializing in post-disruption placements.
If the child was placed privately, either through a lawyer or an adoption agency, that party is usually required by law
to ensure a second placement of the child. However, that requirement is not always enforced, and many parents of
Eastern European adoptees in particular have found their agencies to be of no help in finding a new home for their
children.
Some don't find state social-services agencies to be much help either, since they're already so overwhelmed and they
would have to pay child support. An underground, possibly illegal, network has arisen in the U.S. over the past
337
decade to help these parents disrupt their adoptions, authorities believe. Some of the people in this have taken in
large amounts of children at the same time and have sometimes been arrested for child abuse and neglect.
Attitudes toward disruption

Few parents who have disrupted adoptions have been willing to talk about the process, since it carries a strong social
stigma. It is seen by many as essentially legally sanctioned abandonment, especially since there is no corresponding
legal procedure available for biological parents who find their children beyond their ability to handle.
Those who do disrupt and discuss it describe the experience as, unsurprisingly, extremely painful, almost like a death
in the family, and shameful but ultimately worth it for both the parent and the child. This resolution, however,
usually cannot be reached without undergoing extensive counseling and therapy.
High-profile disruptions
One of the rare public accounts of a disruption took place in 2000 when the CBS News program 48 Hours told the
story of an Atlanta-area couple who ultimately decided to disrupt the adoption of their nine-year-old Russian-born
daughter and return her to the orphanage in Moscow she had previously lived in. The girl had severe reactive
attachment disorder and the family feared for their physical safety due to her increasing violence. Since the girl had
not acquired U.S. citizenship, her treatment options for that were more limited than they might have been for a
domestically-born child.
After she was returned to Russia, Frank Adoption Center, the Washington, D.C.-based agency that had originally
placed her, was able to find a new American family willing to adopt her.
A more recent high-profile case was that of Tristan Dowse, an Indonesian boy adopted by an Irish man, Joe Dowse,
and his Azerbaijani wife, Lala. After two years, Tristan was abandoned at the Indonesian orphanage from where he
had been obtained and adopted, when, according to the Dowses, the adoption "hadn't worked out." At that stage, his
adoption had been recognised by the Irish Adoption Board and he had been granted Irish citizenship. He could only
speak English.
In 2005, investigative journalist Ann McElhinney and Irish Production Company Esras Films reunited the young boy
with his natural mother, Suryani. The resulting documentary The Search for Tristan's Mum was broadcast by Irish
television station RT.
In 2006, an Irish court ordered the Dowses to pay an immediate lump sum of 20,000 to Tristan, maintenance of
350 per month until he is 18 years of age, and a further lump sum of 25,000 when he reaches the age of 18. In
addition, Tristan would remain an Irish citizen and enjoy all the rights to the Dowses estate. Tristans adoption was
struck off the Register of Foreign Adoptions held by the Irish Adoption Board and Suryani was appointed his sole
legal guardian.
In 2010, seven-year-old Artyom Savelyev/Justin Hansen's adoptive mother Torry Ann Hansen sent him back to
Moscow alone with a note explaining why she no longer wanted him.[1]
338
Statistics
Since no records are kept or required to be kept of how many disruptions occur beyond those filed in court, which
are confidential, there is no way to be sure how many are occurring. Anecdotal evidence, however, has suggested
that while they may have decreased as a whole through 1997 (when the Adoption and Safe Families Act was
passed), for adoptions of Eastern-European born children they may well have increased, and thus the rate may have
stabilized.
A U.S. Department of Health and Human Services review [2] of what was known as of 2004 suggests that overall,
10-25% of adoptions are disrupted or dissolved, and that the rate tends to rise with the age of the child at adoption. It
admitted that much data remains to be collected before any clear policies to prevent disruptions can be formulated
and implemented.
A similar review [3] in 2002 by the British Department for Education and Skills, done to lobby for changes in data
collection procedures, also reported the lack of any centrally collected data to work from.
References
[1] Tom Leonard in New York Published: 6:23PM BST 09 Apr 2010 (2010-04-09). "Adopted Russian boy, 7, returned by US mother on
one-way flight to Moscow... alone" (http:/ / www. telegraph. co. uk/ news/ worldnews/ europe/ russia/ 7572387/
Adopted-Russian-boy-7-returned-by-US-mother-on-one-way-flight-to-Moscow. . . -alone. html). Telegraph. . Retrieved 2010-05-14.
[2] http:/ / naic. acf. hhs. gov/ pubs/ s_disrup. cfm
[3] http:/ / www. dfes. gov. uk/ adoption/ adoptionreforms/ consult. shtml
Koch, Wendy; January 18, 2006, Underground network moves children from home to home (http://www.
usatoday.com/news/nation/2006-01-18-swapping-children_x.htm), USA Today.
External links
Disruption (http://www.nurtureadopt.org/af/adoptiondisruption.htm) at nurtureadopt.com.

Directory of disruption-related resources (http://www.karensadoptionlinks.com/disrupt.html)
Explanation of disruption process (http://www.nurtureadopt.org/af/adoptionarticles/disruption.htm)
.PDF on after care for disrupting parents and disrupted adoptees (http://www.mnasap.org/information/
Factsheets/Adoption_Disruption.pdf)
339
Genealogical bewilderment is a term referring to potential identity problems that could be experienced by a child
who was either fostered, adopted, or conceived via an assisted reproductive technology procedure such as surrogacy
or gamete donation (egg or sperm donation). There is some controversy surrounding this topic.
The term was coined in 1964 by psychologist H. J. Sants, referring to the plight of children who have uncertain,
little, or no knowledge of one or both of their natural parents. Sants argued that genealogical bewilderment
constituted a large part of the additional stress that adoptees experienced that is not experienced by children being
raised by their natural parents.[1]
Sants worked in the same clinic as psychiatrist E. Wellisch, who wrote in a 1952 letter to the journal Mental Health,
entitled "Children without genealogy: The problem of adoption":
"Knowledge of and definite relationship to his genealogy is ... necessary for a child to build up his
complete body image and world picture. It is an inalienable and entitled right of every person. There is
an urge, a call, in everybody to follow and fulfill the tradition of his family, race, nation, and the
religious community into which he was born. The loss of this tradition is a deprivation which may result
in the stunting of emotional development.[2]
Sorosky, Pannor and Baran drew upon the work of Sants in a number of publications during the 1970s including a
book entitled The Adoption Triangle, thus exposing the concept of "genealogical bewilderment" to a larger
audience.[2]
Adoptees and search/reunion issues

According to Jones (1997), identity development presents a challenge for adoptees, especially those in closed
adoptions, and describes this "genetic bewilderment" as a logical consequence of a lack of immediate knowledge of
their origins:
"[An issue] that surfaces repeatedly in an adoptee's life is that of identity. The development of an
identity is a crucial building block for self-esteem, and an adoptee's struggle to achieve a coherent story
is often a daunting task. The sense of continuity, of a past and present that is necessary for identity
formation (Glen, 1985/1986) is defied in mandates governing closed adoption" (p. 66).[3]
Levy-Shiff (2001, p.102) elaborated based on findings from a study on adult adoptees:
"Whereas previous studies have documented adoption during childhood and adolescence, the findings of
the present study suggest that during adulthood as well, adoptees are at a higher risk for psychological
maladjustment. Thus they were found, on average, to have a less coherent and positive self-concept and
to manifest more pathological symptomatology than did nonadoptees. ... It has been suggested (Sorosky
et al., 1975; Verrier, 1987) that the difficulties in resolving a sense of coherent and positive self-identity
is tied to four fundamental psychological issues: ... (4) confusion and uncertainty regarding genealogical
continuity, tied to the lack of knowledge about ones ancestors. Accordingly, the lack of biological
mutuality among adoptive family members, such as shared biologically based characteristics regarding
appearance, intellectual skills, personality traits, and so forth, impedes the adoptees ability to identify
with adoptive parents. Moreover, the lack of information about ones biological background is likely to
create a hereditary ghost which may contribute to a confused, unstable, and distorted sense of self. It
is possible that self development does not have closure in adolescence, especially among adoptees, but
continues to evolve over the lifespan through reconciliation and integration of many complex
perceptions, cognitive systems, and self-object representations. (p. 102)."[4]
There is some debate about the contribution of genealogical bewilderment to adoption searches. On other hand,
Storm (1988) in the Psychoanalytic Quarterly, summarizes Humphrey and Humphrey (1986)[5] who state that:
340
"The term genealogical bewilderment refers to a group of psychological problems stemming from lack
of knowledge of one's ancestors. Adopted children and children conceived by artificial insemination
from an anonymous donor are two examples of groups who may suffer from this problem. The literature
is reviewed. Early papers suggested that not knowing about one's ancestors keeps one from developing a
secure self-image. More recent work suggests that good surrogate family relationships lead to good
development, regardless of the lack of information about biological ancestors, and that the drive to
search out biological ancestors usually reflects poor relationships with the surrogate parents."[6]
On the other hand, in a more recent article, Affleck and Steed (2001) state:
"Dissatisfaction with adoptive parents was originally thought to be a motivating factor related to
adoptees' searching (Sorosky, et al., 1975; Triseliotis, 1973). However, more recent research has found
that the vast majority of adoptees who search have positive relationships with adoptive parents (Pacheco
& Eme, 1993) or that the quality of adoptive relationships (either positive or negative) is not associated
with a decision to search (Sachdev, 1993).... In fact, the most common reasons for searching given by
adoptees are related to four themes: "genealogical bewilderment" (adoptees' need for historical
connection to resolve identity issues); a need for information, a need to reduce stigma, and a desire to
assure the [natural parents] of the adoptees' wellbeing" (p. 38).[7]
Judith and Martin Land (2011) address genealogical bewilderment as an important psychological motive for doing
an adoption search, Adoption Detective: Memoir of an Adopted Child, pages 270 and 275. The uncertain state of
genealogical bewilderment is a source of stress, perhaps leaving adoptees more prone to rebellion because they have
no roots or foundation from which to judge their potential. Discovery of genealogical roots is a path to understanding
the true inner being and potential source of psychological grounding. Exposure of this topic to a wider audience is
encouraged.
References
[1]
[2]
[3]
[4]
O'Shaughnessy, T. (1994). Adoption, social work and social theory: Making the connections. Brookfield, VT: Ashgate Publishing, p. 119.
Wellisch, 1952, as quoted by O'Shaughnessy, p. 119
Jones, A. (1997). "Issues relevant to therapy with adoptees". Psychotherapy, 34(1). 64-68.
Levy-Shiff, R. (2001). "Psychological adjustment of adoptees in adulthood: Family environment and adoption-related correlates".
International Journal of Behavioral Development, 25(2) 97-104.
[5] Humphrey, M., & Humphrey, H. (1986). "A fresh look at genealogical bewilderment". British Journal of Medical Psychology, 59(2),
133-140.
[6] Storm, J.E. (1988). British Journal of Medical Psychology. LIX, 1986. Psychoanalytic Quarterly, 57, 288-288. Information retrieved from
PEP Web (http:/ / www. pep-web. org/ document. php?id=paq. 057. 0288a)
[7] Affleck, M. & Steed, L. (2001). "Expectations and Experiences of Participants in Ongoing Adoption Reunion Relationships: A Qualitative
Study". American Journal of Orthopsychiatry, 71(1), 38-48
Further reading
Affleck, M. & Steed, L. (2001). Expectations and Experiences of Participants in Ongoing Adoption Reunion
Relationships: A Qualitative Study. American Journal of Orthopsychiatry, Vol. 71, No.1, 38-48
Frith, L. (2001). Gamete donation and anonymity: The ethical and legal debate. Human Reproduction, Vol. 16,
No. 5, 818-824.
Jones, A. (1997). Issues relevant to therapy with adoptees. Psychotherapy, Vol. 34, No. 1. 64-68.
Levy-Shiff, R. (2001). Psychological adjustment of adoptees in adulthood: Family environment and
adoption-related correlates. International Journal of Behavioral Development, Vol. 25, No.2, 97-104
Roberts, M. (2006). Girl could give birth to sibling. BBC News (http://news.bbc.co.uk/2/hi/health/6264082.
stm)
341

Adopton in the United States is the legal act of adoption, of permanently placing a person under the age of 18 with
a parent or parents other than the birth parents in the United States.
Overview
Domestic U.S. adoptions can fall into two types: agency and independent.[1] Adoption agencies must be licensed by
the state in which they operate.[2] The U.S. government maintains a website, The Child Information Gateway,[3]
which lists every state's licensed agencies. There are both private and public adoption agencies. Private adoption
agencies often focus on infant adoptions, while public adoption agencies typically help find homes for waiting
children, many of them presently in foster care and in need of a permanent loving home.[4] To assist in the adoption
of waiting children, there is a U.S. government-affiliated website, Adopt US Kids,[5] assisting in sharing information
about these children with potential adoptive parents. The North American Council on Adoptable Children provides
information on financial assistance to adoptive parents (called adoption subsidies) when adopting a child with special
needs.[6] Independent adoptions are usually arranged by attorneys and typically involve newborn children.
Approximately 55% of all U.S. newborn adoptions are completed via independent adoption.[7]
The 2000 census was the first census in which adoption statistics were collected. The number of children awaiting
adoption dropped from 132,000 to 118,000 during the period 2000 to 2004 broken link [8].
Foster care system

The United States has a system of foster care by which adults care for minor children who are not able to live with
their biological parents. In fiscal year 2000, 150,703 foster children were adopted in the United States, many by their
foster parents or relatives of their biological parents. The enactment of the Adoption and Safe Families Act in 1997
has approximately doubled the number of children adopted from foster care in the United States. If a child in the
U.S. governmental foster care system is not adopted by the age of 18 years old, they are "aged out" of the system on
their 18th birthday.
Wide impact
Adoption is changing the way people form families, as well as affecting the way society perceives the fundamental
concepts of life such as nature vs. nurture and the role of biological relations with an adoptive family member.
Because of changes in adoption over the last few decades changes that include open adoption, gay adoption,
international adoptions and trans-racial adoptions, and a focus on moving children out of the foster care system into
adoptive families the impact of adoption on the basic unit of society, the family, has been enormous. [9] As
adoption expert Adam Pertman has said, Suddenly there are Jews holding Chinese cultural festivals at synagogues,
there are Irish people with their African American kids at St Patty's Day. This affects whole communities, and as a
consequence our sense of who we are, what we look like, as a people, as individual peoples. These are profound
lessons that adoption is teaching us.
Trans-racial adoption
The adoption of children of one race by parents of another race, which began officially in the United States in 1948,
has always generated controversy[10] . The argument often comes down to opposing views as to who gets to decide
what is the "best interest" of children. Critics of transracial adoption question whether White European American
parents can effectively prepare children of color to deal with racism. Others wonder where the children raised by
White parents will find social acceptance as adults. Testimony from many transracially adopted adults who grew up
342

in White families illustrates the "in-between" status many adoptees feel, not belonging to or feeling comfortable in
communities of color or among White society.[11] Another source of controversy is the history of the widespread
removal of children from families and communities of color, which has been shown by historians to have been a tool
to regulate families and oppress communities, dating back to slavery times and during the now-discredited Indian
Boarding School movement of the early twentieth century[12] . Given this history of child removal, the National
Association of Black Social Workers (NABSW) condemned transracial adoptions in 1972 in their historic Position
Statement. In that paper, the NABSW equated the removal of African American children from their families of
originand their placement in White homeswith "cultural genocide."[13]
Pro-transracial adoption advocates argue that there are more white families seeking to adopt than there are minority
families; conversely, there are more minority children available for adoption. This disparity often results in a lower
cost to adopt children from ethnic minorities - usually through special adoption grants rather than fee discrimination.
Many critics decry the exchange of money for children, whether as "fees for service" or otherwise, arguing that no
children of any race should ever be for sale. Proponents point out practicality in the current systems. This situation is
morally difficult because the adoptive families see adoption as a great benefit to trans-racially adopted children,
while some minorities see it as an assault on their culture. In 2004, 26 percent of African-American children adopted
from foster care were adopted trans-racially.[14] Government agencies have varied over time in their willingness to
facilitate trans-racial adoptions. "Since 1994, white prospective parents have filed, and largely won, more than two
dozen discrimination lawsuits, according to state and federal court records."[14] There is also a great need to place
these children; in 2004 more than 45,000 African-American children were waiting to be adopted from foster care.[14]
Americans have adopted more than 200,000 children from overseas in the past 15 years, half of whom come from
Asia.[14] This trend has helped lower the resistance to trans-racial adoptions in the United States, at least for Asian
and Hispanic children, although there is still high demand for Caucasian children, who usually come from Eastern
Europe.
As the children adopted in the early days of the transracial adoption experiment have reached middle age, a growing
chorus of voices from adult transracial adoptees has emerged. Their collective experience can be found in films[15]
[16]
, scholarly articles, memoirs[17] , blogs[18] , and numerous books on the subject.[19] [20]
Adoption reform
No sooner were US adoptions made secretive with original birth records sealed, than those adopted began to seek
reform. Jean Paton, author of Breaking Silence and founder of Orphan Voyage in 1954, is regarded as the mother of
adoption reform and reunification efforts. Jean Paton mentored adoptee Judith Land, "Adoption Detective: Memoir
of an Adopted Child" during her adoption search. Florence Fisher organized The ALMA Society (Adoptees
Liberation Movement Association) in 1972, Emma May Vilardi created International Soundex Reunion Registry
(ISRR) in 1975, Lee Campbell and other birthmothers joined the fight for Open Records forming Concerned United
Birthparents (CUB) in 1976, and by the spring of 1979 representatives of 32 organizations from 33 states, Canada
and Mexico gathered together in DC to establish the American Adoption Congress (AAC). TRIADOPTION
Library began keeping records in 1978 showing 52 search/support/reform organizations, by 1985 there were over
550 worldwide.TRIADOPTION Archives [13]
Adoption Reform encompasses family preservation, adoptees access to original birth certificates, birth and adoptive
families having direct access to each other (open adoption) and all related records (open records).
The Adoption Triangle by Annette Baran, Reuben Pannor and Arthur Sorosky; Twice Born and Lost and Found by
Betty Jean Lifton; I Would Have Searched Forever by Sandra Musser; The Adoption Searchbook: Techniques for
Tracing People by Mary Jo Rillera; The Politics of Adoption by Mary Kathleen Benet; all published in the 1970s and
still in print, were instrumental in examining and defining the foundation of reform. Adoption Books [21]
As of February, 2009, 24 U.S. states have legal provisions for enforceable open adoption contact agreements.[22].
Each year additional states consider law changes that give persons separated by adoption access to information about
343

themselves and each other. State Laws [23]
ISRR - International Soundex Reunion Registry [12]

TRIADOPTION Archives [13]
CUB [24]
AAC [25]
ALMA [26]
Search and reunion

Many adopted people who were separated from their birth parents by adoption have a desire to reunite, and most
would like family medical history information and access to any documents where they are mentioned. Often, birth
parents who placed their infants want to reunite as well. In states which practice or have practiced confidential
adoption, this has led to the creation of adoption reunion registries, and efforts to establish the right of adoptees to
access their sealed records (for example, see AAC - American Adoption Congress, CUB - Concerned United
Birthparents, Bastard Nation). Others join search and support groups, most of which are non-profit, or some hire
investigative companies (see Adoption Search and Reunion) to locate birth families and adopted children.
International adoption refers to adopting a child from a foreign country. American citizens represent the majority of
international adoptive parents, followed by Europeans and those from other more developed nations. The laws of
different countries vary in their willingness to allow international adoptions. Some countries, such as China, Korea
and Vietnam, have very well established rules and procedures for foreign adopters to follow, while others, the United
Arab Emirates (UAE) for example, expressly forbid it. International adoptions by Americans became much more
common after the Korean War when American servicemen fathered interracial children with Korean women. China
is the leading country for international adoptions by Americans.
The U.S. Department of State has designated two accrediting entities for organizations providing inter-country
adoption services in the United States that work with sending countries that have ratified the Hague Treaty. They are
the Council on Accreditation and the Colorado Department of Health and Human Services. [5] The U.S. Department
of State maintains a list of all accredited international adoption providers. [6]
Facilitators
There are also individuals who act on their own and attempt to match waiting children, both domestically and
abroad, with prospective parents, and in foreign countries provide additional services such as translation and local
transport. They are commonly referred to as facilitators. Since in many jurisdictions their legal status is uncertain
(and in some U.S. states they are banned outright), they operate in a legal gray area.
Where the law does not specifically allow them to, all they can do is make an introduction, leaving the details of the
placement to those legally qualified to do so. But in practice, their role as gatekeepers can give them a great deal of
power to direct a particular child to a particular client, or not, and some have been accused of using this power to
defraud prospective adoptive parents.
344
References
[1] ADOPTING IN AMERICA: How To Adopt Within One Year, by Randall Hicks, WordSlinger Press 2005
[2] http:/ / www. adoption101. com/ agency_adoption. html
[3] http:/ / www. childwelfare. gov/ nfcad/
[4] ADOPTION: The Essential Guide to Adopting Quickly and Safely, by Randall Hicks, Perigee Press 2007
[5] http:/ / www. adoptuskids. org
[6] http:/ / www. nacac. org/ adoptionsubsidy/ adoptionsubsidy. html
[7] http:/ / www. adoption101. com/ independent_adoption. html
[8] http:/ / www. acf. hhs. gov/ programs/ cb/ stats_research/ afcars/ trends. htm%20USA%20Adoption%20Chart
[9] http:/ / www. adoptioninstitute. org/ survey/ survey_summary. html
[10] H. Fogg-Davis (2002). The Ethics of Transracial Adoption
[11] Simon & Roorda (2000).
[12] Shin, Oparah, & Trenka (2006)
[13] Source: Robert H. Bremner, Children and Youth in America: A Documentary History, Vol. 3, Parts 1-4 (Harvard University Press,
1974):777-780.
[14] Overcoming Adoptions Racial Barriers (http:/ / www. nytimes. com/ 2006/ 08/ 17/ us/ 17adopt. html) by Lynette Clemets and Ron Nixon,
The New York Times, August 17, 2006
[15] "Hoard, D. (1998) "Struggle for Identity: Issues in Transracial Adoption"
[16] Bertelsen, Phil. Outside Looking In: Transracial Adoption in America
[17] John. J/ Black Baby, White Hands: A View from the Crib
[18] [John Raible Online], Harlow's Monkey, Twice the Rice
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
Shin, Oparah, and Trenka (eds.) Outsiders Within: Writing on Transracial Adoption. Boston: South End Press.
Simon, R. & Roorda, R. In Their Own Voices: Transracial Adoptees Tell Their Stories.
http:/ / www. isrr. net/ books. shtml
http:/ / childwelfare. gov/ systemwide/ laws_policies/ statutes/ cooperative. cfm
http:/ / www. childwelfare. gov/ systemwide/ laws_policies/ state/
http:/ / www. cubirthparents. org/
http:/ / www. americanadoptioncongress. org/
http:/ / www. almasociety. org/
External links
childwelfare.gov - The Child Welfare Information Gateway (http://www.childwelfare.gov/)
adoption101.com - Informational articles on all aspects of adoption (http://adoption101.com/)
Open Adoption - a commericial web site about how to achieve an open adoption (http://www.openadoption.
com/)
TRIADOPTION Archives - Search Support Reform History (http://www.triadoption.com/)
The Adoption History Project (http://www.uoregon.edu/~adoption/)
(http://www.mercatornet.com/index.php?option=com_content&task=view&id=205) - "International
adoptions: the role of the media". MercatorNet, 29 December 2005 - Adam Pertman, Executive Director of the
Evan B. Donaldson Adoption Institute, on the media perceptions.
345
Adoption in Italy
Adoption in Italy
Adoptions in Italy numbered 4,130 in 2010[1] . This figure relates to overseas adoptions, domestic adoption from
within Italy being relatively difficult.
In 2006 there were 11,000 couples in Italy on the waiting lists of various adoption agencies[2] .
As in most jurisdictions, prospective adoptive parents are required to undergo assessment and must show that they
will make suitable parents. Italian law[3] requires adopters to be married (or living together) for at least 3 years.
There are also restrictions on the age difference between the prospective parents and the child or children they wish
to adopt. Adoption by gay couples is illegal in Italy, as is adoption by single parents.
According to statistical data published by the Italian Commissione per le Adozioni Internazionali[4] , 2010 was the
year with the highest number of international adoptions by Italian couples. The Commission for International
Adoptions, chaired by Undersecretary Senator Carlo Giovanardi, granted entry in Italy to 4130 children from 58
countries, up from 3964 in 2009 (4.2% increase), 639 of which were special needs children.
The first country of origin is the Russian Federation with 707 children, but there was a particularly high increase in
the number of children from Colombia, who numbered 592 compared to 444 of 2009. Colombia is therefore the
second largest country of origin, followed by Ukraine with 426 adoptions, Brazil with 318, Ethiopia with 274,
Vietnam with 251 and Poland with 193.
There was a significant increase of children from Latin America (+16.34%) and Asia (+34.71%) despite changes in
domestic laws taking place in countries such as Vietnam, Cambodia and Nepal. Children from African countries
numbered 443.
The Italian region with the highest number of adoptions is Lombardy, followed by Latium, Tuscany and Veneto, but
a significant increase was noted in the southern regions, especially Campania, Apulia, Calabria and Sardinia. The
only region where international adoptions in 2010 decreased by 14% was Sicily.
Foreign children adopted by Italian couples in 2010 were on average 6 years old, up from 5.9 in 2009.
References
[1] (http:/ / www. commissioneadozioni. it/ it/ notizie/ 2011/
comunicato-stampa-4130-bambini-adottati-dalle-coppie-italiane-nel-2010-(3012011). aspx) Commissione Adozioni Internazionali
[2] (http:/ / www. guardian. co. uk/ italy/ story/ 0,,2000691,00. html) The Guardian
[3] Art. 6 of law 184/83 (modified by law 149/2001)
[4] http:/ / www. commissioneadozioni. it/ media/ 68239/ prereport_adozioni2010. pdf
External Links
Official website of the Italian Commission for International Adoptions (http://www.commissioneadozioni.it)
Website of the Italian Court of Minors, Adoptions Department (http://www.tribunaledeiminori.it/adozione.
php)
346
Adoption in France
Adoption in France
Adoption in France is codified in the French Civil Code in two distinct forms: simple adoption and plenary
adoption.
Simple adoption
Simple adoption (French: adoption simple) is a type of adoption which allows some of the legal bonds between an
adopted child and his or her birth family to remain. It is formalized under articles 343 and following of the French
Civil Code.
Simple adoption is less restrictive in its requirements and less radical in effects than plenary adoption.
Requirements for adoption

A single person of 29 years or older can adopt another person.
It is necessary for the adoptive parent to be at least 15 years older than the adoptee, unless the adoptee is the child
of the adoptive parent's spouse. In this case, the parent must be 10 years older than the adoptee.
If the prospective adoptive parent is married, the consent of the spouse is needed. (Articles 361 and following of
the Civil Code)
Consequences
Adoption grants to the adoptee rights and duties equivalent to those of a legitimate child. Thus, for example, the
name of the adoptive parents is added to the adoptee's original name, or replaces it.
The adoptive parents gain exclusive parental authority over the child, though legal bonds of the adoptee with his
or her family of origin are not broken. Thus, the adoptee preserves inheritance rights within his original family.
The simple adoptee (and his children and stepchildren) have the ability to inherit from both families.
The adoptee cannot inherit from the parents of the adoptive parents.
An exception is made if the adoptive parent has children resulting from a preceding marriage.
If the adoptee dies and leaves successors, rights of inheritance are determined by common law. If not, inheritance
is divided, half going to the birth family and half to the adoptive family.
Adoption has no consequences for the nationality of the adoptee, who can be of foreign nationality (this is
possible if there are agreements with France).
There is a maintenance obligation (obligation alimentaire) between the adoptee and adoptive parent. Between the
adoptee and his birth parents, a similar obligation also exists, but it is only secondary: birth parents are bound by
the obligation alimentaire only if the adoptee establishes that he or she could not obtain help from the adoptive
parents.
347
Adoption in France
Age of adoptee
There is no condition on the age of the adoptee. The assent of the adoptee is necessary for adoptees of 14 years
and older, and, for minor adoptees the agreement of his parents is needed.
The future adoptee; no retractation after having given the agreement.
There are no particular restrictions for adoptees past the age of majority.
Plenary adoption
Plenary adoption (French: adoption plnire) is an alternate form of adoption which terminates the relationship
between birth parent and child[1] . Thus, all rights and status which the child may have had from the birth family are
revoked and replaced with the rights and status granted by the adopting family.
The term "plenary adoption" distinguishes it from the other form of adoption practised in France, simple adoption,
which allows some of the legal bonds between an adopted child and his or her birth family to remain.
References
[1] "Adoption Glossary: Plenary adoption" (http:/ / www. adoption. ca/ glossary. htm#plenaryadoption). . Retrieved 2008-07-07.
External links
http://www.notaires.fr/notaires/notaires.nsf/V_TC_PUB/FRANCE-ADOPTION (in French)
Adoption is the legal act of permanently placing a person under the age of 18 with a parent or parents other than the
birth parents. Australia allows local adoptions (placement within the country), known child adoptions (adoption by
relatives, stepparents or carers), and intercountry adoptions (adoption of children born overseas). Adoptions are
handled by state and territorial government agencies, such as Adoption Services Queensland and the Department of
Human Services in Victoria.
Statistics
There has been a substantial decline in the number of adoptions in Australia since the early 1970s. In 197172 there
were 9,798 adoptions, which declined to 1,052 in 199192, and 576 in 200506.[1] [2] A report by the Australian
Bureau of Statistics attributes this decline to the introduction of welfare for single mothers, increased legal access to
termination of pregnancy, family planning services, access to child care and improved participation of women in the
workforce.[2]
As the table below demonstrates, Australia has a significantly lower rate of adoption than the United States and the
United Kingdom:
348
Country
349
Adoptions
[3]
Live Births
Australia
502 (20032004)
England &
Wales
4,764 (2006)
669,601(2006)
United States
approx 127,000
[7]
(2001)
4,021,725
[8]
(2002)
[5]
Adoption/Live Birth
Ratio
Notes
[4]
0.2 per 100 Live Births
Includes all adoptions
[6]
0.7 per 100 Live Births
Includes all adoption orders in England and Wales
~3 per 100 Live Births
The number of adoptions is reported to be constant

since 1987.
254,000 (2004)
Low rates of domestic adoptions are attributed to the low number of children who need placement. Low rates of
international adoptions are attributed to long wait times (from two to as much as eight years) and high cost (up to
$40,000). The following table shows the most recent adoption figures, from the Australian Institute of Health and
Welfare[9] :
20052006 20062007 20072008 20082009
Intercountry adoptions
421
405
270
269
Local adoptions
60
59
70
68
104
100
104
'Known-child' adoptions 95
Totals
576
568
440
441
Stolen generations
The Stolen Generations (also Stolen children) refers to those children of Australian Aboriginal and Torres Strait
Islander descent who were removed from their families by the Australian Federal and State government agencies and
church missions, under acts of their respective parliaments.[10] [11] The removals occurred in the period between
approximately 1869[12] and 1969,[13] [14] although in some places children were still being taken in the 1970s.[15]
The earliest introduction of child removal to legislation is recorded in the Victorian Aboriginal Protection Act 1869.
The Central Board for the Protection of Aborigines had been advocating such powers since 1860, and the passage of
the Act gave the colony of Victoria a wide suite of powers over Aboriginal and 'half-caste' persons, including the
forcible removal of children, especially 'at risk' girls.[16] By 1950, similar policies and legislation had been adopted
by other states and territories.[17] According to the Bringing Them Home inquiry into the forced separation of
indigenous children from their families, less than 17% of the children were adopted. The majority of these adoptions
occurred after 1950 when authorities began promoting the fostering and adoption of Aboriginal children by white
parents.
Changing attitudes
While the first adoption legislation in Australia in the 1920s fostered relatively "open" adoptions, a second wave of
legislation passed in the 1960s had emphasised the importance of a "clean break" from birth parents and enshrined
the principle of secrecy around the adoptive status of children, who were to be raised by their adoptive parents "as if
born to them". This principle was meant to provide adoptive parents with heirs without fear of stigma or interference
from the biological parent/s, but also operated to allow the unmarried mother, her child, and her family, to be
shielded from the shame of an "illegitimate" birth.[18]
Subsequent revelations decades later of the history of the treatment of "removed" children, whether indigenous,
white Australian, or the British children who travelled to Australia in imperial forced migration schemes well into
the twentieth-century, had a profound impact on public perceptions of adoption. The notion of "coming home",
mobilised with great effect by indigenous Australians to account for their experiences of separation from family into
institutions or adoption, came to stand for the adoptive experience generally. This concept stigmatised adoptions in
general as entailing loss, removal from roots, and pain while at the same time idealised the birth family, minimising
if not shutting out the role and experiences of the adoptive family.[18]
Recognition of the damaging effects of previous adoption policies had burgeoned in the 1970s and 1980s. Beginning
in the mid-1970s, all Australian states and territories reviewed adoption legislation and embarked on initially
cautious reversals of previous (secretive) practices throughout the 1980s. National Adoption Conferences, convened
in Australia in 1976, 1978 and 1982, brought together people affected by adoption with professionals and
researchers. These conferences served as important for a for activism and agitation on adoption law reform. Workers
in the field began to tend towards the view that children should be with their biological parents where possible.[18]
Sociologist Rosemary Pringle suggested as late as 2002 that adoption in Australia had lost virtually all social policy
credibility.
Then, in 2005 and again in 2007, in two significant reports from the House of Representatives Standing Committee
on Family and Human Services, adoption appeared to reemerge on the political agenda as viable social policy. The
2005 report endorsed not only intercountry adoption, but suggested that adoption, rather than foster care and other
out-of-home-care, might also be in the best interests of many Australian-born children. It also reversed the
Australian tendency towards non-interventionism in family matters. The Standing Committee emerged from its
investigations, by its own admission, "unequivocally in support of intercountry adoptions as a legitimate way to give
a loving family environment to children from overseas who may have been abandoned or given up for adoption".
This is contrasted with the negative attitudes to adoption found within the state and territory welfare departments
responsible for processing adoption applications at the time. These attitudes ranged "from indifference to
hostility".[18]
Intercountry adoptions
Intercountry adoption in Australia first began in 1975 during the Vietnam War when 292 Vietnamese orphans were
transported to Australia in 'Operation Babylift'.[19] An average of 330 intercountry adoptions were finalised each
year for the ten years between 1998 and 2008.[19] The rate of children being adopted from China has increased faster
than any other country from 0.3% in the 19992000 period to 30.9% in the 200607 period. In the 20072008
period, the majority of intercountry adoptions have come from, in descending order, China (63 children, 23.3%),
South Korea (47 children, 17.4%), Philippines (41 children, 15.2%) and Ethiopia (35 children, 13.0%).[19] As of
August 2009, Australia has open programs with Bolivia, Chile, China, Colombia, Ethiopia, Fiji, Hong Kong, India,
Lithuania, Philippines, South Korea, Sri Lanka, Taiwan, and Thailand. Countries with whom adoption programs
have closed include Costa Rica, Guatemala, Mexico and Romania.[20]
The Australian Government Attorney-General's Department has primary responsibility for developing and
maintaining intercountry adoption arrangements with other countries. This responsibility is shared with the State and
Territory authorities, which assess appplications, facilitate adoptions, provide advice and assistance, and provide
post-placement support and supervision.[21] Applicants must meet the eligibility requirements set by the Australian
State or Territory in which the application is being lodged. Each overseas country also has eligibility criteria that
applicants must meet. Intercountry adoption can be a lengthy process, usually taking at least two years in Australia,
requiring multiple assessments of the continued suitability of prospective parents.[22]
Intercountry adoption practices comply with the principles of the Hague Convention on Intercountry Adoption,
which came into force in Australia on 1 December 1998. It is implemented by the Family Law Act 1975 and the
Family Law (Hague Convention on Intercountry Adoption) Regulations 1998. The Australian Citizenship Act 2007
simplified the process of obtaining Australian citizenship for children who were adopted overseas in accordance with
the Hague Convention.
Family Law (Hague Convention on Intercountry Adoption) Regulations 1998 [23]
Australian Citizenship Act 2007 [24]
350
Known child adoptions

Family law in Australia with regards to children is based on what is considered to be in the best interest of the child.
Family laws contain a strong preference for retaining ties to biological parents, and a general presumption against
making a known adoption order because an adoption order severs the legal relationship between the child and one of
the childs birth parents. Due to the serious consequences of an adoption order, all stepparent adoption laws contain a
strong preference for dealing with new parenting arrangements through a parenting order rather than an adoption
order. Stepparents and other carers may apply to the Family Court of Australia for a parenting order, as other people
significant to the care, welfare and development of the child. It provides an important "status quo" if the birth
mother were to die, so, for example, other family members could not come and take the child.
Same sex couples

Adoption for same-sex couples is currently available in Australian Capital Territory (since 2004), New South Wales
(since 2010) and Western Australia (since 2002).[25] In Tasmania, only stepparent adoption is allowed (since
2004).[26] In Queensland, Northern Territory, Victoria and South Australia, same-sex couples cannot legally adopt a
child under their adoption legislation,[27] but can become foster parents.[28] Single LGBT people may adopt in all
states/territories (except in South Australia which bans all single people from adoption), but individuals seeking to
adopt are considered less of a priority than couples and lengthy waiting lists for adoption make it virtually
impossible. Individuals may usually only adopt a child with special needs or in cases of exceptional circumstances.
Both South Australia and Tasmania are currently considering legislation in allowing the adoption of children for
same-sex couples after recent elections this year, won by the Labor party which promised to "review" the current
adoption legislation.
Queensland, Victorian and the Northern Territory governments have no plans to review or change the law, to allow
same sex couples the right to adopt children.
Western Australia became the first Australian state to allow same-sex adoptions when its Labor government passed
the Acts Amendment (Lesbian and Gay Law Reform) Act, 2002 which in turn amended the Adoption Act, 1994 (WA).
This allowed same-sex couples to adopt in accordance with criteria that assesses the suitability of couples and
individuals to be parents, regardless of sexual orientation.
Australia's first legal gay adoption, by two men, occurred in Western Australia in June 2007.[29] [30] [31] [32]
Subsequently, on 2 August 2007, the federal government under Prime Minister John Howard announced it would
legislate to stop same-sex couples adopting a child from overseas, and would further not recognise adopted children
of same-sex couples. The federal Coalitions proposed Family Law (Same Sex Adoption) Bill would amend the 1975
Family Law Act and override state and territory laws that currently cover international adoptions. The bill was due to
be introduced in the spring 2007 session of parliament, but has been taken off the agenda following the 2007 federal
election.[33] [34]
State laws
Each State and Territory also has its own legislation governing local and intercountry adoption matters within that
State and Territory. In addition to the adoption acts, each state has corresponding regulations. As of 2011, Tasmania
and South Australia are currently undertaking parliamentary reviews of their adoption laws.
ACT: Adoption Act 1993 [35]
NSW: Adoption Act 2000 [36]
NT: Adoption of Children Act 1994 [37]
QLD: Adoption Act 2009 [38]
SA: Adoption Act 1988 [39]
TAS: Adoption Act 1988 [40]
351
VIC: Adoption Act 1984 [41]
WA: Adoption Act 1994 [42]
References
[1] "Adoption Fact Sheet". Children by Choice.
[2] Australian Bureau of Statistics. "Australian Social Trends, 1998" (http:/ / www. abs. gov. au/ ausstats/ abs@. nsf/
2f762f95845417aeca25706c00834efa/ c14cbc586a02bfd7ca2570ec001909fc!OpenDocument). .
[3] Australian Institute of Health and Welfare, Adoptions Australia 200304 (http:/ / www. aihw. gov. au/ publications/ cws/ aa03-04/ aa03-04.
pdf), Child Welfare Series Number 35.
[4] Australian Bureau of Statistics, Population and Household Characteristics (http:/ / www. abs. gov. au/ AUSSTATS/ abs@. nsf/
ViewContent?readform& view=ProductsbyTopic& Action=Expand& Num=5. 12. 2)
[5] UK Office for National Statistics, Adoption Data (http:/ / www. statistics. gov. uk/ CCI/ nugget. asp?ID=592& Pos=1& ColRank=2&
Rank=384)
[6] UK Office for National Statistics, Live Birth Data (http:/ / www. statistics. gov. uk/ cci/ nugget. asp?id=369)
[7] The National Adoption Information Clearinghouse of the U.S. Department of Health and Human Services, How Many Children Were
Adopted in 2000 and 2001 (http:/ / www. ncsconline. org/ WC/ Publications/ KIS_AdoptStatistics. pdf), 2004
[8] U.S. Center for Disease Control, Live Births (http:/ / www. cdc. gov/ nchs/ data/ hus/ hus05. pdf#summary)
[9] (http:/ / www. aihw. gov. au/ publications/ cws/ 36/ 10858. pdf)
[10] Bringing them Home, Appendices listing and interpretation of state acts regarding 'Aborigines' (http:/ / www. austlii. edu. au/ au/ special/
rsjproject/ rsjlibrary/ hreoc/ stolen/ stolen62. html): Appendix 1.1 NSW (http:/ / www. austlii. edu. au/ au/ special/ rsjproject/ rsjlibrary/ hreoc/
stolen/ stolen63. html); Appendix 1.2 ACT (http:/ / www. austlii. edu. au/ au/ special/ rsjproject/ rsjlibrary/ hreoc/ stolen/ stolen64. html);
Appendix 2 Victoria (http:/ / www. austlii. edu. au/ au/ special/ rsjproject/ rsjlibrary/ hreoc/ stolen/ stolen65. html); Appendix 3 Queensland
(http:/ / www. austlii. edu. au/ au/ special/ rsjproject/ rsjlibrary/ hreoc/ stolen/ stolen66. html); Tasmania (http:/ / www. austlii. edu. au/ au/
special/ rsjproject/ rsjlibrary/ hreoc/ stolen/ stolen67. html); Appendix 5 Western Australia (http:/ / www. austlii. edu. au/ au/ special/
rsjproject/ rsjlibrary/ hreoc/ stolen/ stolen68. html); Appendix 6 South Australia (http:/ / www. austlii. edu. au/ au/ special/ rsjproject/
rsjlibrary/ hreoc/ stolen/ stolen69. html); Appendix 7 Northern Territory (http:/ / www. austlii. edu. au/ au/ special/ rsjproject/ rsjlibrary/ hreoc/
stolen/ stolen70. html).
[11] Bringing them home education module (http:/ / www. humanrights. gov. au/ education/ bth/ contents. html#resources): the laws: Australian
Capital Territory (http:/ / www. humanrights. gov. au/ education/ bth/ resources/ laws_act. html); New South Wales (http:/ / www.
humanrights. gov. au/ education/ bth/ resources/ laws_nsw. html); Northern Territory (http:/ / www. humanrights. gov. au/ education/ bth/
resources/ laws_nt. html); Queensland Queensland (http:/ / www. humanrights. gov. au/ education/ bth/ resources/ laws_qld. html); South
Australia (http:/ / www. humanrights. gov. au/ education/ bth/ resources/ laws_sa. html); ; Victoria (http:/ / www. humanrights. gov. au/
education/ bth/ resources/ laws_vic. html); Western Australia (http:/ / www. humanrights. gov. au/ education/ bth/ resources/ laws_wa. html).
[12] Marten, J.A., (2002), Children and war, NYU Press, New York, p. 229 ISBN 0-8147-5667-0.
[13] Australian Museum (2004). "Indigenous Australia: Family" (http:/ / www. dreamtime. net. au/ indigenous/ family. cfm#bi). . Retrieved 28
March 2008.
[14] Read, Peter (1981) (PDF). The Stolen Generations: The Removal of Aboriginal children in New South Wales 1883 to 1969 (http:/ / www.
daa. nsw. gov. au/ publications/ StolenGenerations. pdf). Department of Aboriginal Affairs (New South Wales government).
ISBN0-646-46221-0. .
[15] In its submission to the Bringing Them Home report, the Victorian government stated that "despite the apparent recognition in government
reports that the interests of Indigenous children were best served by keeping them in their own communities, the number of Aboriginal
children forcibly removed continued to increase, rising from 220 in 1973 to 350 in 1976" ( Bringing Them Home: "Victoria" (http:/ / www.
austlii. edu. au/ au/ special/ rsjproject/ rsjlibrary/ hreoc/ stolen/ stolen10. html)).
[16] M.F. Christie, Aboriginal People in Colonial Victoria, 183586, pp. 175176.
[17] Such as the Aboriginal Protection and restriction of the sale of opium act 1897 (Qld), the Aborigines Ordinance 1918 (NT), the Aborigines
Act 1934 (SA) and the 1936 Native Administration Act (WA). For more information, see Bringing them Home, appendices listing and
interpretation of state acts regarding 'Aborigines' (http:/ / www. austlii. edu. au/ au/ special/ rsjproject/ rsjlibrary/ hreoc/ stolen/ stolen62.
html).
[18] Kate Murphy, Marian Quartly, Denise Cuthbert (2009). ""In the best interests of the child": mapping the emergence of pro-adoption politics
in contemporary Australia" (http:/ / findarticles. com/ p/ articles/ mi_go1877/ is_2_55/ ai_n32452187/ ). bNet. . Retrieved 2 September 2008.
[19] "History of Intercountry Adoption in Australia" (http:/ / www. ag. gov. au/ www/ agd/ agd. nsf/ Page/
IntercountryAdoption_HistoryofintercountryadoptioninAustralia). Australian Government Attorney-General's Department. . Retrieved 2
September 2008.
[20] "Current Intercountry Adoption Programs" (http:/ / www. ag. gov. au/ www/ agd/ agd. nsf/ Page/
IntercountryAdoption_Currentintercountryadoptionprograms). Australian Government Attorney-General's Department. . Retrieved 2
September 2008.
[21] "Roles of the Commonwealth, States and Territories" (http:/ / www. ag. gov. au/ www/ agd/ agd. nsf/ Page/
IntercountryAdoption_RolesoftheCommonwealth,StatesandTerritories). Australian Government Attorney-General's Department. . Retrieved 2
352
September 2008.
[22] "Adoption of a child" (http:/ / www. birth. com. au/ Difficulty-conceiving/ Adoption-of-a-child. aspx). Birth. . Retrieved 3 September 2008.
[23] http:/ / www. comlaw. gov. au/ comlaw/ management. nsf/ lookupindexpagesbyid/ IP200400893?OpenDocument
[24] http:/ / www. comlaw. gov. au/ comlaw/ management. nsf/ lookupindexpagesbyid/ IP200614688?OpenDocument
[25] "Adoption Act 1994 Section 39 Criteria for application" (http:/ / www. austlii. edu. au/ au/ legis/ wa/ consol_act/ aa1994107/ s39. html).
Austlii. . Retrieved 1 May 2008.
[26] "Adoption Act 1988, Section 20" (http:/ / www. austlii. edu. au/ au/ legis/ tas/ consol_act/ aa1988107/ s20. html). Austlii. . Retrieved 1 May
2008.
[27] (http:/ / www. austlii. edu. au/ au/ legis/ qld/ num_act/ aa2009n29134/ )
[28] "Same sex couples" (http:/ / web. archive. org/ web/ 20080325223758/ http:/ / www. legalaid. qld. gov. au/ Legal+ Information/
Relationships+ and+ children/ Relationships/ Same+ sex+ couples. htm). Legal Aid Queensland. Archived from the original (http:/ / www.
legalaid. qld. gov. au/ Legal+ Information/ Relationships+ and+ children/ Relationships/ Same+ sex+ couples. htm) on 25 March 2008. .
Retrieved 1 May 2008.
[29] "Gay adoption 'groundbreaking'" (http:/ / www. news. com. au/ perthnow/ story/ 0,21598,21898760-2761,00. html). PerthNow. . Retrieved
13 May 2008.
[30] "First Legal Gay Adoption In Australia" (http:/ / www. samesame. com. au/ news/ local/ 905/ First_Legal_Gay_Adoption_In_Australia).
SameSame.com.au. . Retrieved 13 May 2008.
[31] "Australias First Legal Adoption For Gay Couple" (http:/ / www. efluxmedia. com/
news_Australia8217s_First_Legal_Adoption_For_Gay_Couple_06505. html). efluxmedia. . Retrieved 13 May 2008.
[32] "Australia's First Gay Adoption" (http:/ / www. proudparenting. com/ node/ 390). ProudParenting.com. . Retrieved 13 May 2008.
[33] "Green Left Stop the proposed same-sex adoption ban" (http:/ / www. greenleft. org. au/ 2007/ 720/ 37376). Green Left. . Retrieved 13
May 2008.
[34] "Gay couples face overseas adoption ban" (http:/ / www. smh. com. au/ news/ National/ Same-sex-couples-face-adoption-ban/ 2007/ 08/ 02/
1185648030026. html). Sydney Morning Herald. 2 August 2007. . Retrieved 13 May 2008.
[35] http:/ / www. legislation. act. gov. au/ a/ 1993-20/ default. asp
[36] http:/ / www. legislation. nsw. gov. au/ fullhtml/ inforce/ act+ 75+ 2000+ FIRST+ 0+ N
[37] http:/ / notes. nt. gov. au/ dcm/ legislat/ legislat. nsf/ d989974724db65b1482561cf0017cbd2/
ec3341f7d3a8b7fb692575180081c0a6?OpenDocument
[38] http:/ / www. austlii. edu. au/ au/ legis/ qld/ num_act/ aa2009n29134/
[39] http:/ / www. legislation. sa. gov. au/ LZ/ C/ A/ ADOPTION%20ACT%201988. aspx
[40] http:/ / www. thelaw. tas. gov. au/ tocview/ index. w3p;cond=;doc_id=41+ + 1988+ AT@EN+ 20080214140000;histon=;prompt=;rec=;term
[41] http:/ / www. legislation. vic. gov. au/
[42] http:/ / www. slp. wa. gov. au/ legislation/ statutes. nsf/ main_mrtitle_6_homepage. html
Australia's poor adoption record (http://www.abc.net.au/unleashed/stories/s2135022.htm), Unleashed,

Australian Broadcasting Commission
External links
Department of Immigration and Citizenship, Fact Sheet 36 Adopting Children from Overseas (http://www.
immi.gov.au/media/fact-sheets/36adopting.htm)
Australian Citizenship Act 2007 and the Australian Citizenship (Transitionals and Consequentials) Act 2007
1 July 2007 Legislation change (http://www.immi.gov.au/legislation/amendments/2007/070701/
lc01072007-05.htm)
Australian Department of Families, Community Services and Indigenous Affairs Adoption (http://www.
community.gov.au/Internet/MFMC/community.nsf/pages/section?opendocument&Section=Adoption)
Attorney-General's Department Intercountry Adoption (http://www.ag.gov.au/www/agd/agd.nsf/Page/
IntercountryAdoption_CountryPrograms_IntercountryAdoption)
Australian Institute of Family Studies (http://www.aifs.gov.au/institute/afrc7/kellys.html) Adoption in
Australia An Overview
Australian Institute of Health and Welfare (http://www.aihw.gov.au/publications/index.cfm/title/10858)
Australian adoption statistics
Adoption.org (http://www.adoption.org/adopt/adoption-agencies-australia.php) Adoption agencies in

Australia
353
The current laws in Guatemala allow private adoptions like in the United States. This type of adoption is also the
most popular way of adopting from Guatemala. In 2006 4,135 children[1] were adopted from Guatemala, most of
them via private adoptions. In these cases the adoptions are usually handled by attorneys who represent the adoptive
parents and handle all the necessary paperwork in Guatemala. Technically a different attorney represents the child
that is being adopted. In many cases the adoptive parents may not have any direct contact with their attorney in
Guatemala since they are usually represented by a middle man or an adoption agency in their home country.
Private adoptions are basically a contract between the biological parent and the adoptive parents stating that the
biological parent relinquishes all rights to the child and allows to adoptive parents to adopt the child. To prevent
irregularities biological parents have to be interviewed by a social worker at the so called Family Court. Thereafter
Guatemala's Attorney General's office, also called PGN (Procuradura General de la Nacin),[2] scrutinizes all
available documents before allowing the adoption process to be finalized. If the adoptive parents reside in the United
States, the stringent rules of the US embassy in Guatemala have to be followed before the adopted child can receive
an immigration visa to enter the USA. These rules include two DNA tests to ensure the person who relinquishes the
child is the child's parent. The first DNA test has to be performed before the file enters PGN. The US embassy has an
agreement with PGN that no adoptions for US residence can be approved before a DNA test has proven the child's
identity. The second test will be performed after PGN to prevent a child swap during the adoption process. After
PGN gives its approval to the adoption the biological parent of the child needs to sign off one last time on the
relinquishment. After that the child is by Guatemalan law the child of the adoptive parents. Following a new birth
certificate will be issued by the municipality where the child was born. The new birth certificate states the adoptive
parents as father and mother of the child. At the same time a second DNA test will be performed. With this new birth
certificate a passport will be issued for the child and the paperwork will be submitted to the US embassy again in
cases where the adoptive parents live in the USA. The embassy scrutinizes the paperwork again and eventually
issues an immigration visa to the adopted child.
The time frame for adoption from Guatemala varies greatly. It depends on many factors such as political climate and
the quality of the adoption professionals that handle the paperwork. When the political climate was positive or
indifferent towards adoptions from Guatemala some cases were processed in less than 3 months. In the current
political climate there are many administrative obstacles. Cases that are being processed in less than 6 months are
currently exceptional. Some cases may one year or longer from start to completion.
Calls for reform

The private adoption system in Guatemala has been criticized by organizations such as UNICEF. These
organizations lobby for a so called 'adoption reform' in Guatemala and in the United States. UNICEF wants
adoptions to be handled completely by government institutions.[3] Unfortunately these so called reforms have caused
a complete shut down of international adoptions in other counties that have implemented these reforms. The
governments of these, often third world countries, are usually not capable of implementing efficient adoption
processes with the result that foreign adoptions completely cease. This condemns many children, who would have
had the chance of finding a caring home in a foreign country, to live in underfunded orphanages or on the streets.
354
References
[1] Guatemala Adoption Overview at Adoptive Families (http:/ / www. adoptivefamilies. com/ guatemala_adoption. php)
[2] www.dittmerfamily.com - Guatemala adoptions (http:/ / www. dittmerfamily. com/ guatemalaadoptions)
[3] Guatemala Adoption Information and News: On UNICEF and ICA (http:/ / www. guatadopt. com/ archives/ 000513. html)
External links
Dateline NBC report on Guatemalan adoption (http://www.msnbc.msn.com/id/22731006/)
LGBT adoption
LGBT adoption is the adoption of children by lesbian, gay, bisexual and transgender (LGBT) persons. This may be
in the form of a joint adoption by a same-sex couple, adoption by one partner of a same-sex couple of the other's
biological child (step-parent adoption), and adoption by a single LGBT person.
Adoption by same-sex couples is legal in 14 countries as well as in the jurisdictions of several more. Adoption by
same-sex couples is however prohibited by a majority of countries, although debates in many jurisdiction take place
to allow it. The main concern raised by those opposed to LGBT adoption is the question of whether same-sex
couples have the ability to be adequate parents. As the matter is often not specified by law (or deemed
unconstitutional), legalization often takes place via judicial opinions.
A consensus has developed among the medical, psychological, and social welfare communities that children raised
by gay and lesbian parents are just as likely to be well-adjusted as those raised by heterosexual parents.[1] The
research supporting this conclusion is accepted beyond serious debate in the field of developmental psychology.[2]
Based on the robust nature of the evidence available in the field, Third District Court of Appeal State of Florida was
satisfied in 2010 that the issue is so far beyond dispute that it would be irrational to hold otherwise; the best interests
of children are not preserved by prohibiting homosexual adoption.[3]
LGBT parenting
The existing body of research on outcomes for children with LGBT parents includes limited studies that consider the
specific case of adoption. Moreover, where studies do mention adoption they often fail to distinguish between
outcomes for unrelated children versus those in their original family or step-families, causing research on the more
general case of LGBT parenting to be used to counter the claims of LGBT-adoption opponents.[4] One study has
addressed the question directly, evaluating the outcomes of adoptees less than 3-years old who had been placed in
one of 56 lesbian and gay households since infancy. Despite the small sample and the fact that the children have yet
to become aware of their adoption status or the dynamics of gender development, the study found no significant
associations between parental sexual orientation and child adjustment, making the results consistent with notions that
two parents of the same gender can be capable parents and that parental sexual orientation is not related to parenting
skill or child adjustment. The findings point to the positive capabilities of lesbian and gay couples as adoptive
parents.[5]
Objections to and support for LGBT adoption

Adoption of children by LGBT people is an issue of active debate. In the United States, for example, legislation to
stop the practice has been introduced in many jurisdictions; such efforts have largely been defeated, with the
exception of Arkansas Act 1. There is agreement between the debating parties, however, that the welfare of children
alone should dictate policy.[4] Supporters of LGBT adoption suggest that many children are in need of homes and
claim that since parenting ability is unrelated to sexual orientation, the law should allow them to adopt children.[4]
355
LGBT adoption
356
Opponents, on the other hand, suggest that the alleged greater prevalence of depression, drug use, promiscuity and
suicide among homosexuals (and alleged greater prevalence of domestic violence) might affect children [6] or that
the absence of male and female role models could cause maladjustment.[7] Catholic Answers, a Catholic religious
group, in its 2004 report on gay marriage addressed parenting by homosexual partners via adoption or artificial
insemination. It pointed to studies finding higher than average abuse rates among heterosexual stepparent families
compared with families headed by biological parents.[8] [9] The American Psychological Association, however, notes
that an ongoing longitudinal study found that none of the lesbian mothers had abused their children. It states that
fears of a heightened risk of sexual abuse by gay parents are not supported by research.[10]
Several professional organizations have made statements in defense of adoption by same-sex couples. The American
Psychological Association has supported adoption by same-sex couples, citing social prejudice as harming the
psychological health of lesbians and gays while noting there is no evidence that their parenting causes harm.[11] [12]
[13]
The American Medical Association has issued a similar position supporting same-sex adoption, stating that
while there is little evidence against the practice, lack of formal recognition can cause health-care disparities for
children of same-sex parents.[14]
Britain's last Catholic adoption society announced that it would stop finding homes for children if forced by
legislation to place children with same-sex couples.[15] The Muslim Council of Britain also sided with Catholic
adoption agencies on this issue. [16] Catholic Charities of Boston also ended its founding mission of adoption work
rather than comply with state laws conflicting with its religious practices.[17]
Public opinion
A 2006 poll by the Pew Research Center found a close divide on gay adoption among the United States public, while
a 2007 poll by CNN and Opinion Research Corp. said 57% of respondents felt gays should have the right to adopt
and 40% said they should not.[18] In the United Kingdom in 2007, 64% of people said they thought gay couples
should be allowed to adopt and 32% said they should not. 55% of respondents thought that male couples should be
able to adopt and 59% of people thought that lesbian couples should be able to adopt.[19] In Brazil, a 2010 poll
asked, "Do you support or oppose allowing gay couples to adopt children?" The poll found that 51% opposed
adoption by same-sex couples and 39% supported it.[20] An opinion poll conducted in late 2006 at the request of the
European Commission indicated that Polish public opinion was generally opposed to both same-sex marriage and to
adoption by gay couples. The Eurobarometer 66[21] poll found that 74% of Poles were opposed to same-sex marriage
and 89% opposed adoption by same-sex couples.
Legal status around the world

Full joint adoption by same-sex
couples is currently legal in the
following countries:
Andorra (2005)[22]
Argentina (2010)[23]
Belgium (2006)[24]
Brazil (2010)[25]
Canada (1999 onward, depending
on province)[26] [27] [28] [29] [30] [31]
Denmark (2010)[32]
Iceland (2006)[33]
Netherlands (2001)[34]
Norway (2009)[35]
Legal status of adoption by same-sex couples around the world. Gay adoption
legalStep-child adoptionUnknown/Ambiguous or illegal
LGBT adoption
South Africa (2002)[36]

Spain (2005)[37]
Sweden (2002)[38]
United Kingdom: England and Wales (2005),[39] Scotland (2009)[40] and Northern Ireland (unclear).[41]
Uruguay (2009)[42] [43]
Full joint adoption by same-sex couples is currently legal in the following jurisdictions:
Australia: Western Australia (2002),[44] Australian Capital Territory (2004),[44] and New South Wales (2010).[45]
Mexico: Mexico City (2010)[46]
United States: the District of Columbia (1995),[47] New Jersey (1998),[48] New York (2002),[47] Indiana
(2006),[47] Maine (2007),[47] California,[47] Connecticut,[47] Illinois,[47] Massachusetts,[47] Oregon,[47]
Vermont,[47] Florida[49] and the unincorporated territory of Guam.[44]
In the following countries, "stepchild-adoption" is permitted, so that the partner in a registered partnership (or
unregistered cohabitation in Israel) can adopt the natural (or sometimes even adopted) child of his or her partner:
Finland (2009)[50]
Germany (2004)[22]
Greenland (2009)
Israel (2005)[22] (Israel allowed overseas adoption and full joint adoption in several cases[51] [52] )
Slovenia (2011) [53]

In the following jurisdictions, "stepchild-adoption" is permitted, so that the partner in a civil union can adopt the
natural (or sometimes even adopted) child of his or her partner:
Australia: Tasmania (2004)[44]
United States: Pennsylvania (2002)[47]
Africa
South Africa
South Africa is the only African country to allow joint adoption by same-sex couples. The 2002 decision of the
Constitutional Court in the case of Du Toit v Minister of Welfare and Population Development amended the Child
Care Act, 1983 to allow both joint adoption and stepparent adoption by "permanent same-sex life partners".[54] The
Child Care Act has since been replaced by the Children's Act, 2005, which allows joint adoption by "partners in a
permanent domestic life-partnership", whether same- or opposite-sex, and stepparent adoption by a person who is the
"permanent domestic life-partner" of the child's current parent.[55] Same-sex marriage has been legal since 2006, and
is equivalent to opposite-sex marriage for all purposes, including adoption.
357
LGBT adoption
358
Asia
Israel
A January 2005 ruling of the Israeli
Supreme Court allowed stepchild adoptions
for same-sex couples. Israel previously
allowed limited co-guardianship rights for
non-biological parents.[56] Then in February
2008, a court in Israel ruled that same-sex
couples are now permitted to adopt a child
even if that child is not biologically related
Legal status of adoption by same-sex couples in part of West Asia and in Egypt
to either parent.[57] This marked a watershed
Gay adoption legalGay adoption illegalHomosexuality
in granting equal rights to all gay people in
illegalUnknown/Ambiguous
[57]
Israel.
isRealli, the official blog of the
State of Israel, frequently publishes updates
on gay adoption news in Israel. The site also has a complete timeline of gay rights milestones in Israel.
Europe
In February 2006, France's Court of
Cassation ruled that both partners in a
same-sex relationship can have parental
rights over one partner's biological child.
The result came from a case where a woman
tried to give parental rights of her two
daughters to her partner whom she was in a
civil union with.[58] In the case of adoption,
however, in February 2007, the same court
ruled against a lesbian couple where one
partner tried to adopt the child of the other
partner. The court stated that the woman's
partner cannot be recognized unless the
mother withdrew her own parental rights.[59]
[60]
Legal status of adoption by same-sex couples in Europe Gay adoption
legalStepchild adoption legalGay adoption illegalUnknown/Ambiguous, except
in Andorra, where gay adoption is legal
In 1998, a nursery school teacher from

Lons-le-Saunier, living as a couple with
another woman, had applied for an
authorization to adopt a child from the dpartement (local government) of Jura. The adoption board recommended
against the authorization because the child would lack a paternal reference, and thus the president of the dpartement
ruled against the authorization.[61] The case was appealed before the administrative courts and ended before the
Council of State, acting as supreme administrative court, which ruled against the woman.[62] The European Court of
Human Rights concluded that these actions and this ruling were a violation of Article 14 of the European Convention
on Human Rights taken in conjunction with Article 8.[61] [63]
On June 2, 2006, the Icelandic Parliament unanimously passed a proposal accepting adoption, parenting and assisted
insemination treatment for same-sex couples on the same basis as heterosexual couples. The law went into effect on
June 27, 2006.
LGBT adoption
359
North America
Canada
In
Canada,
adoption
is
within
provincial/territorial jurisdiction, and thus
the laws may differ from one province or
territory to another. Adoption by same-sex
couples is legal in every province and
territory.[26] [27] [28] [29] [30]
Mexico
In Mexico City, the Legislative Assembly of
the Federal District passed legislation on 21
December 2009 enabling same-sex couples
to adopt children.[64] Eight days later, Head
of Government ("Mayor") Marcelo Ebrard
signed the bill into law, which officially
took effect on 4 March 2010.[46] [65]
United States
Legal status of adoption by same-sex couples in North America. Gay adoption
legalStep-child adoptionGay adoption illegalUnknown/Ambiguous

According to a report by the Williams
Institute, in 2007 there were 270,000
children in the United States who lived with same-sex couples. Of these, one-quarter, or 65,000, were adopted.[66]
In the U.S., states may restrict adoption by sexual orientation or marital status. Furthermore, since adoptions are
mostly handled by local courts in the United States, some judges and clerks accept or deny petitions to adopt on
criteria that vary from other judges and clerks in the same state,[67] leading to a confused or ambiguous legal status
for same-sex parents in some states.
According to Lambda Legal, which has represented many same-sex couples in state and federal courts:[68]
The rights of LGBT parents vary widely among states. About half of all states permit second-parent
adoptions by the unmarried partner of an existing legal parent, while in a handful of states courts have
ruled these adoptions not permissible under state laws. This leaves parents in many states legally
unrecognized or severely disadvantaged in court fights with ex-spouses, ex-partners or other relatives.
Additionally, barriers exist in assisted reproduction and related medical care, and discrimination and
irrational stereotypes and fears about sexual orientation, gender identity and HIV persist.
LGBT adoption
Utah
Utah and Florida are among the states that historically imposed more stringent restrictions of LGBT adoption. Utah
prohibits adoption by "a person who is cohabiting in a relationship that is not a legally valid and binding
marriage,"[69] making it legal for single people to adopt, regardless of sexual orientation, so long as they are not
co-habitating in non-marital relationships.
Florida
In Florida, adoption by homosexuals was expressly forbidden by a law passed by the 1977 Legislature, in the wake
of the anti-gay Save Our Children campaign led by Anita Bryant. However, in November 2008, the law was struck
down by state circuit court Judge Cindy Lederman in the case In re: Gill, involving a gay male couple raising two
young foster children placed with them in 2004 by state child welfare workers.
In her ruling granting the adoption, Lederman found that the law violated the Florida Constitution's equal protection
guarantees for the children and their adoptive parents; she added that there was no rational basis to prohibit gay
parents from adopting, particularly since the scientific evidence of the suitability of gay parents is extensive, and the
state allows them to act as foster parents.[70] The state appealed Judge Lederman's decision.
On September 22, 2010, the Third District Court of Appeals of the State of Florida unanimously upheld the decision
of the lower court. On October 22 of that year, Attorney General Bill McCollum subsequently announced that the
State of Florida would not appeal the court's ruling, thus ending the 33-year-old ban on gay adoptions in Florida.[71]
Arkansas
On November 4, 2008, Arkansas voters approved Act 1, a measure to ban anyone "co-habitating outside of a valid
marriage" from being foster parents or adopting children. Although the law could apply to heterosexual couples, it
was believed to have been written to target gay couples due to the fact that same-sex marriage is prohibited in that
state, thereby making an adoption impossible.[72] Single gay men and lesbians were still allowed to adopt in
Arkansas. The law was overturned on April 16, 2010 by state judge Chris Piazza.[73] The Arkansas Supreme Court
upheld the lower court's decision on April 7, 2011.[74]
Louisiana
In December 2008, in the case of Adar v. Smith, a U.S. District Court in Louisiana "ordered the state registrar to
honor the New York adoption of a baby boy by a same-sex couple, saying her continued failure to do so violated"
the Full Faith and Credit Clause of the U.S. Constitution, and directed that the state issue a new birth certificate for
the child listed both men as parents.[75]
However, the Attorney General of Louisiana appealed the decision, and on April 12, 2011, the Fifth Circuit Court of
Appeals overturned the district court ruling, holding that "the full faith and credit clause does not oblige Louisiana to
confer particular benefits on unmarried adoptive parents contrary to its law. . . . Louisiana has a right to issue birth
certificates in the manner it deems fit."[76]
Oceania
In Australia, same-sex adoption is legal in the Australian Capital Territory,[77] Western Australia[78] and New South
Wales,[45] while only stepchild adoption within a registered relationship under the Relationships Act 2003 is possible
in Tasmania. The lesbian co-mother or gay co-father(s) can apply to the Family Court of Australia for a parenting
order, as 'other people significant to the care, welfare and development' of the child. But the lesbian co-mother and
gay co-father(s) will be treated in the same way as a social parent is treated under the law; they will not be treated in
the same way as a birth parent.[79] In May 2007, the Victorian Law Reform Commission in Victoria released its final
report recommending that the laws be modified to allow same sex couples to adopt children have not been
implemented yet, while all other recommendations have been implemented.[80]
360
LGBT adoption
361
In New Zealand, preliminary New Zealand Law Commission reports and white papers have raised the issue already,
while Metiria Turei, a Green Party of New Zealand List MP raised the issue in late May 2006. In February 2005, the
Greens had suggested that an adoption law reform clause should be added to the Relationships (Statutory
References) Act 2005, which equalized heterosexual, lesbian and gay spousal status in New Zealand law and
regulatory policy, apart from the Adoption Act 1955. While the measure was unsuccessful, it remains to be seen
whether a reintroduced adoption law reform bill on its own would fare differently.[81]
South America
In Argentina, Brazil and Uruguay same-sex
couples
can
jointly
adopt.
A
government-sponspored adoption law in
Uruguay allowing LGBT adoption was
approved by the lower house on 28 August
2009, and by the Senate on 9 September
2009. In October 2009, the law was signed
by President and took effect.[43] According
to Equipos Mori Poll's, 53% of Uruguayans
oppose to same sex adoption against 39%
that support it. Interconsult's Poll made in
2008 says that 49% oppose to same sex
adoption against 35% that support it.[42] [82]
In Paraguay, single persons can adopt, but
couples are given preference and the latter
must be heterosexual. However, if the
adoptive parent will adopt as a single parent,
sexual orientation per se constitutes no legal
impediment.[83]
Legal status of adoption by same-sex couples in Latin America and the

CaribbeanGay adoption legalStep-child adoptionGay adoption
illegalHomosexuality illegalUnknown/Ambiguous
Summary of laws by jurisdiction

European laws on adoption by same-sex couples
Country
LGBT individual may

petition to adopt
Same-sex couple may

jointly petition
Same-sex partner may petition

to adopt partner's child
Same-sex couples are allowed to

foster or stepchild foster
Belgium
Yes
Yes
Yes
Yes
Denmark
Yes
Yes
Yes
Yes
Estonia
Yes
No
No
Yes
Finland
Yes
No
Yes
Yes
France
Yes
No
Yes
Yes
Germany
Yes
No
Yes
Yes
Iceland
Yes
Yes
Yes
Yes
Ireland
Yes
No
No
Yes
Italy
No
No
No
No (but singles can exceptionally

foster)
LGBT adoption
Latvia
362
Yes
No
No
No?
No (only in exceptional
circumstances)
No
No
No
Netherlands
Yes
Yes
Yes
Yes
Norway
Yes
Yes
Yes
Yes
Poland
Yes
No
No
No
Portugal
Yes
No
No
No (but singles can foster)
Slovenia
Yes
No
Yes
Yes
Spain
Yes
Yes
Yes
Yes
Sweden
Yes
Yes
Yes
Yes
United
Kingdom
Yes
Yes
Yes
Yes
Lithuania
US States' laws on adoption by same-sex couples[84]

State
LGBT individual may petition to

adopt
Same-sex couple may jointly

petition
Same-sex partner may petition to adopt

partner's child
Alabama
Yes
No explicit prohibition
In some jurisdictions
Alaska
Yes
Arizona
Yes
Unclear
Arkansas
Yes
Yes
Yes
California
Yes
Yes
Yes
Colorado
Yes
Yes
Yes
Connecticut
Yes
Yes
Yes
Delaware
Yes
District of
Columbia
Yes
Yes
Yes
Florida
Yes
Yes
Yes
Georgia
Yes
Unclear
Hawaii
Yes
Idaho
Yes
Unclear
Unclear
Illinois
Yes
Yes
Yes
Indiana
Yes
Yes
Yes
Iowa
Yes
Yes
Yes
Kansas
Yes
Unclear
Kentucky
Yes
Unclear
Louisiana
Yes
Maine
Yes
Yes
Yes
Maryland
Yes
Massachusetts
Yes
Yes
Yes
Michigan
Yes
No
[85]
[74]
[85]
[85]
LGBT adoption
363
Minnesota
Yes
Mississippi
Yes
No
Missouri
Yes
Montana
Yes
Unclear
Nebraska
Unclear
No
Nevada
Yes
Yes
Yes
New Hampshire
Yes
Yes
Yes
New Jersey
Yes
Yes
Yes
New Mexico
Yes
New York
Yes
Yes
Yes
North Carolina
Yes
Unclear
No
[86]
[86]
Unclear
[87]
[89]
[90]
[88]
[89]
[89]
[90]
North Dakota
Unclear
Unclear
Ohio
Unclear
Unclear
[91]
[91]
Oklahoma
Yes
Unclear
Oregon
Yes
Yes
Yes
Pennsylvania
Yes
Unclear
Yes
[92]
Yes
[92]
South Carolina
Yes
Unclear
Unclear
South Dakota
Yes
Unclear
Unclear
Tennessee
Yes
Unclear
Texas
Yes
Utah
Yes
No
No
Vermont
Yes
Yes
Yes
Virginia
Yes
Unclear
Washington
Yes
Yes
Yes
West Virginia
Yes
Unclear
Wisconsin
Yes
No
Wyoming
Yes
Unclear
Rhode Island
[92]
[92]
[93]
[94]
No
[93]
[94]
Unclear
LGBT adoption
364
Latin American and Caribbean laws on adoption by same-sex couples

Same-sex couple joint petition
LGBT individual adoption
Same-sex stepparent adoption
Argentina
Yes
Yes
Yes
Brazil
Yes
Yes
Yes
Chile
No
No
No
Colombia
No
Yes
No
Paraguay
No
No
No
Surinam
No
No
No
French Guyana
No
Yes
Yes
Guyana
No (Homosexuality illegal)
Belize
Peru
No
No
No
Cuba
No
No
No
Puerto Rico
No
Yes
No
Bolivia
No
No
No
Ecuador
No (constitutional ban)
Honduras
El Salvador
No
No
No
Guatemala
No
No
No
Venezuela
No
No
No
Dominican Republic No
No
No
Nicaragua
No
No
No
Costa Rica
No
Yes
No
Mexico
Yes (only Mexico City)
Yes
Yes (only Mexico City)
Uruguay
Yes
Yes
Yes
Australian laws on adoption by same-sex couples

Same-sex couple joint petition
ACT
Yes
New South Wales
Yes
[45]
LGBT individual adoption
Same-sex stepparent adoption
Yes
Yes
Yes
Yes
[45]
Northern Territory No
Only in exceptional circumstances No
Queensland
No
Yes
No
South Australia
No
No
No
Tasmania
No (under review since 2003)
Yes
Yes
Victoria
No (under review since 2007)
Yes
Yes
Yes
Yes
Western Australia Yes
Notes:
Even a de facto opposite sex couple can not jointly adopt a child under the law of the Northern Territory.
LGBT adoption
No individual or single people are allowed to adopt a child, only a married or de facto opposite sex couples under
the law of South Australia.
Further reading
Lerner, Brenda Wilmoth & K. Lee Lerner (eds) (2006). Gender issues and sexuality : essential primary sources..
Thomson Gale. ISBN1414403259. Primary resource collection and readings. Library of Congress. Jefferson or
Adams Bldg General or Area Studies Reading Rms
Lerner, Brenda Wilmoth & K. Lee Lerner (eds) (2006). Family in society : essential primary sources.. Thomson
Gale. ISBN1414403305. Primary resource collection and readings. Library of Congress. Jefferson or Adams
Bldg General or Area Studies Reading Rms
Stacey, J. & Davenport, E. (2002) Queer Families Quack Back, in: D. Richardson & S. Seidman (Eds) Handbook
of Lesbian and Gay Studies. (London, SAGE Publications), 355-374.
New Zealand Law Commission: Adoption- Options for Reform: Wellington: New Zealand Law Commission
Preliminary Paper No 38: 1999: ISBN 1-877187-44-5
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2007-09-27.
[68] "Adoption and Parenting," Lambda Legal, accessed 8 July 2011 (http:/ / www. lambdalegal. org/ issues/ adoption-parenting/ )
[69] Utah Code Section 78B-6-117(3) (http:/ / le. utah. gov/ ~code/ TITLE78B/ htm/ 78B06_011700. htm)
[70] Miami judge rules against Fla. gay adoption ban (http:/ / www. usatoday. com/ news/ nation/ 2008-11-25-gay-adoption_N. htm)
[71] Florida Court Calls Ban on Gay Adoptions Unlawful (http:/ / www. nytimes. com/ 2010/ 09/ 23/ us/ 23adopt. html?ref=adoptions)
[72] Gay-Adoption Ban Passes in Arkansas (http:/ / www. diversityinc. com/ public/ 4727. cfm)
[73] State judge overturns Ark. adoption ban law (http:/ / www. google. com/ hostednews/ ap/ article/
ALeqM5g_NaSygTu-ReLNhPrlZgSsuZyD-QD9F4CTMG0)
[74] Decision striking down US state's law barring gay or unmarried foster, adoptive parents upheld (http:/ / www. google. com/ hostednews/
canadianpress/ article/ ALeqM5hyZvwbTP4xqS7znsExAKYlPtosJA?docId=6493794)
[75] "Federal Court Judge Orders Louisiana Registrar to Recognize Out-of-State Adoption by Lambda Legal Client Couple," Lambda Legal,
accessed 8 July 2011 (http:/ / www. lambdalegal. org/ news/ pr/ la_20081223_fed-court-orders-la-registrar-recognize-out-of-state-adoption.
html)
[76] Adar v. Smith Decision, U.S. Court of Appeals for the Fifth Circuit, Rehearing En Banc, 12 April 2011, accessed 8 July 2011 (http:/ / www.
lambdalegal. org/ in-court/ legal-docs/ adar_la_20110413_decision-us-court-of-appeals-5th-circuit. html)
[77] ADOPTION ACT 1994 - SECT 39 Criteria for application (http:/ / www. austlii. edu. au/ au/ legis/ wa/ consol_act/ aa1994107/ s39. html)
[78] "Australian state votes for adoption by same-sex couples" (http:/ / www. thehindu. com/ news/ international/ article609038. ece). Deutsche
Presse-Agentur. The Hindu. September 2, 2010. . Retrieved September 2, 2010.
[79] Human Rights and Equal Opportunity Commission (http:/ / www. humanrights. gov. au/ human_rights/ samesex/ report/ Ch_5. html)
[80] Victorian Law Reform Commission - Current projects - Assisted Reproduction and Adoption - Final Report (http:/ / www. lawreform. vic.
gov. au/ CA256A25002C7735/ All/ E98CC6AE987CD2FBCA2572F40009BEDB?OpenDocument& 1=30-Current+ projects~&
2=70-Assisted+ Reproduction+ and+ Adoption~& 3=70-Final+ Report~)
[81] (http:/ / www. stuff. co. nz/ stuff/ 0,2106,3675250a6160,00. html)
[82] "Uruguay votes to allow gay adoptions" (http:/ / www. news. com. au/ heraldsun/ story/ 0,21985,25992606-5005961,00. html). Melbourne
Herald Sun. 2009-08-28. . Retrieved 2009-08-27.
[83] Paraguayan Adoption Law (http:/ / www. badaj. org/ ckfinder/ userfiles/ files/ Nacionales/ Paraguay/ Ley_de_adopcion-Paraguay. pdf)
Legal Database, Inter-American Children's Institute, Organization of American States. In Spanish. Retrieved on 20 September 2010.
[84] "Adoption" (http:/ / www. hrc. org/ issues/ parenting/ adoptions/ adoption_laws. asp). HRC. . Retrieved 2010-09-13.
[85] State regulatory code allows delaying or denying an adoption based on sexual orientation. With same-sex marriage now legal, how this
would apply to married same-sex couples is uncertain.
[86] Mississippi allows unmarried adults and married couples to petition, amended in 2000 to prohibit "couples of the same gender" from
adopting.
[87] http:/ / www. hrc. org/ issues/ 1099. htm
[88] http:/ / www. hrc. org/ 1340. htm
[89] (http:/ / www. lawjournalbuffalo. com/ news/ article/ current/ 2010/ 09/ 23/ 102582/ new-law-allows-unmarried-couples-to-adopt)
[90] A 2003 law states: "A child-placing agency is not required to perform, assist, counsel, recommend, facilitate, refer or participate in a
placement that violates the agency's written religious or moral convictions or policies." This is expected to allow some agencies to deny
367
LGBT adoption
placement with LGBT couples and individuals. N.D. CENT. CODE 50-12-03.
[91] HRC | Oklahoma Adoption Law (http:/ / www. hrc. org/ issues/ parenting/ adoptions/ 1370. htm)
[92] The Rhode Island Family Court routinely grants same sex couple adoptions and has been doing so for over fifteen years. The couples do not
necessarily have to reside in Rhode Island and may be having their own birth child, using a surrogate or adopting a child already placed with
them. If you adopt in Rhode Island you will receive a decree listing both partners as parents. If you are able to give birth in Rhode Island, you
will also receive a birth certificate including both parents. After the adoption, the Rhode Island Department of Health, Division of Vital
Statistics will amend a locally born child's birth certificate to name both partners as parents. Greenwood and Fink (Providence, RI) - all legal
services for same sex adopting couples and more. (http:/ / www. lesbiangayadoption. com)
[93] http:/ / www. hrc. org/ 1790. htm
[94] http:/ / www. wiadoptioninfocenter. org/ snav/ 159/ page. htm
External links
New Family Social (https://www.newfamilysocial.co.uk/) The organisation for LGBT adopters and foster
carers in the UK.
AICAN Australian Intercountry Adoption Network (http://www.aican.org/)
National Center for Lesbian Rights (http://www.nclrights.org) Information about the legal rights of lesbian,
gay, bisexual and transgender people and their families, including a legal information hotline
Gay.com Adoption and Parenting (http://www.gay.com/news/roundups/package.html?sernum=362&
navpath=/channels/families/parenting) News and Current Events pertaining to the rights and responsibilities
of same-sex parents in adopting and parenting
Family Pride Coalition (http://www.familypride.org/) The only US-based national level non-profit
organization solely dedicated to advocating for LGBT parents and their families
Families Like Ours (http://www.familieslikeours.org/) Adoption resource center with a focus on same-sex
parenting
The Rockway Institute (http://rockway.alliant.edu) for LGBT research in the public interest at Alliant
International University
COLAGE ([[Children of Lesbians and Gays Everywhere (http://www.COLAGE.org/)])]
Canada.com "In the Family Way" (http://www.canada.com/ottawacitizen/news/story.
html?id=7f508a13-abed-43cc-a346-f18fbd30250e&k=15909&p=1) News story of gay and lesbian adoptive
families, and the surrogate and donor family
Families Like Mine (http://www.familieslikemine.com/)
Greenwood and Fink - all legal services for same sex adopting couples and more. (http://www.
lesbiangayadoption.com/) Providing a path to gay and lesbian adoption: all legal services, access to obstetric
and pediatric medical services, accommodations, social services, concierge services and other resources.
368
Child laundering
Child laundering
Child laundering is the stealing and selling of children to adopting parents under false pretenses. Often the adoption
agency or adoption facilitator hides or falsifies the child's origin to make the child appear to be a legitimate orphan
by manipulating birth certificates, intake records, or records regarding the deaths of the child's parents who might
still be alive. These children are often taken against either their will or the will of their parents to be sold to foreign
adopting parents who are given the false papers and false assurances as to the child's point of origin.
Adoption agencies may sometimes be unknowing or knowing participants in the transactions but most adoptions are
facilitated by adoption agencies. This type of activity most often appears in international adoptions and is a specific
form of child trafficking[1] [2] [3] [4] [5]
The term child laundering expresses the claim that the current intercountry adoption system frequently
takes children illegally from birth parents, and then uses the official processes of the adoption and legal
systems to launder them as legally adopted children. Thus, the adoption system treats children in a
manner analogous to a criminal organization engaged in money laundering, which obtains funds
illegally but then launders them through a legitimate business. [6]
References
[1] David M. Smolin, Child Laundering: How the Intercountry Adoption System Legitimizes and Incentivizes the Practices of Buying,
Trafficking, Kidnapping, and Stealing Children (http:/ / law. bepress. com/ expresso/ eps/ 749/ ), also published by the Wayne Law Review.
[2] David M. Smoin, Unpublished: Child Laundering As Exploitation: Applying Anti-Trafficking Norms to Intercountry Adoption Under the
Coming Hague Regime (http:/ / works. bepress. com/ david_smolin/ 4/ )
[3] David M. Smolin, The Two Faces of Intercountry Adoption: The Significance of the Indian Adoption Scandals (http:/ / works. bepress. com/
cgi/ viewcontent. cgi?article=1001& context=david_smolin), Seton Hall Law Review
[4] (http:/ / www. adoptinginternationally. com/ analysis/ articles/ indianscandallaws. pdf) Adopting Internationally Website
[5] David M. Smolin, Intercountry Adoption as Child Trafficking, Valparaiso Law Review (http:/ / works. bepress. com/ cgi/ viewcontent.
cgi?article=1002& context=david_smolin)
[6] http:/ / law. bepress. com/ cgi/ viewcontent. cgi?article=3679& context=expresso Quote from Page 115
369
Trafficking of children is a form of human trafficking. It is defined as the recruitment, transportation, transfer,
harboring, or receiving of children for the purpose of exploitation.
Commercial sexual exploitation of children can take many forms, including forcing a child into prostitution,[1] other
forms of sexual activity, or child pornography. Child exploitation can also include forced labor or services, slavery
or practices similar to slavery, servitude, the removal of organs, illicit international adoption, trafficking for early
marriage, recruitment as child soldiers, for use in begging, as athletes (such as child camel jockeys or football
players), or for recruitment for cults.[2]
According to international legislation, in the case of children, the use of force or other forms of coercion, such as
abduction, fraud, deception, the abuse of power, or a position of vulnerability does not need to be present in order for
the crime to be considered trafficking.[3] The UN Protocol to Prevent, Suppress and Punish Trafficking in Persons,
especially Women and Children also defines child trafficking as trafficking in human beings. The International
Labor Organization convention 182 defines it as a form of child labor.
Defining child trafficking

There is a tendency for the trafficking debate to gravitate into an approach against criminals on the one hand and an
approach supporting human rights or protection on the other hand. This creates a false impression of opposing
perspectives when both dimensions are inherently linked and essential to prevent and combat trafficking.[4]
Despite its importance in any approach to the trafficking problem, there is no single definition of exploitation, and
there is difficulty in determining the point at which exploitation begins.
The Palermo definition is not limited to cross-border traffickingbetween neighboring Statesand can be applied
to both internal and intercontinental trafficking.
There are potential links between trafficking and migration. When people move from place to place at local,
national, or international levels, they are likely to become more vulnerable, particularly at times of political crisis or
in the face of social or economic pressures. Whether driven by desperate situations or motivated to seek better
opportunities in life, they may willingly consent to being smuggled across a border. Once transported across the
border, they may find themselves abducted into a trafficking network, unable to escape and without access to legal
advice or protection.[5]
International legislation
The United Nations Protocol to Prevent, Suppress and Punish Trafficking in Persons, especially Women and
Children supplements the United Nations Convention against Transnational Organized Crime (2000). The Protocol
had been ratified by 135 countries.[6]
The International Labour Organization's Worst Forms of Child Labour Convention, 1999 (No. 182) [7] defines it as a
form of child labour.
Under both conventions, a child is any person younger than eighteen years of age
Other relevant Conventions
ILO Forced Labour Convention, 1930 (No. 29) [8]
ILO Abolition of Forced Labour Convention, 1957 (No. 105) [9]
ILO Minimum Age Convention, 1973 (No. 138) [10]
370
References
[1] British-born teenagers being trafficked for sexual exploitation within UK, police say | Society | The Guardian (http:/ / www. guardian. co. uk/
society/ 2008/ jul/ 03/ childprotection. internationalcrime)
[2] uefa.com (http:/ / www. uefa. com/ uefa/ keytopics/ kind=2048/ newsid=462974. html)
[3] (http:/ / untreaty. un. org/ English/ TreatyEvent2003/ Texts/ treaty2E. pdf)
[4] UNICEF Innocenti Report on Child Trafficking in Africa (http:/ / www. unicef-irc. org/ publications/ pdf/ insight9e. pdf)
[5] UNICEF Innocenti Report on Child Trafficking in Africa (http:/ / www. unicef-irc. org/ publications/ pdf/ insight9e. pdf)
[6] UNODC - Signatories to the CTOC Trafficking Protocol (http:/ / treaties. un. org/ Pages/ ViewDetails. aspx?src=TREATY&
mtdsg_no=XVIII-12-a& chapter=18& lang=en)
[7] http:/ / www. ilo. org/ ilolex/ cgi-lex/ convde. pl?C182
External links
International Labour Office. (2005). A global alliance against forced labour (http://www.ilo.org/sapfl/
Informationresources/ILOPublications/lang--en/docName--WCMS_081882/index.htm)
ILO Minimun Estimate of Forced Labour in the World. (2005) (http://www.ilo.org/sapfl/
Informationresources/ILOPublications/lang--en/docName--WCMS_081913/index.htm)
The Cost of Coercion ILO 2009 (http://www.ilo.org/sapfl/Informationresources/ILOPublications/lang--en/
docName--WCMS_106268/index.htm)
Operational Indicators of Trafficking in Human Beings 2009 (http://www.ilo.org/sapfl/Informationresources/
Factsheetsandbrochures/lang--en/docName--WCMS_105023/index.htm) ILO/SAP-FL
Lists of Indicators of Trafficking in Human Beings 2009 (http://www.ilo.org/sapfl/Informationresources/
Factsheetsandbrochures/lang--en/docName--WCMS_105884/index.htm) ILO/SAP-FL
IACAC - International Agency for Crimes Against Children - Child Exploitation, Trafficking, & Cyber Crimes
Tactical Initiative (http://www.iacac.eu)
ChildTrafficking.com: Extensive searchable library of scholarly resources (http://www.childtrafficking.com/
Content/Library/)
National Society for the Prevention of Cruelty to Children (UK): In-depth reading list of academic articles on the
topic (http://www.nspcc.org.uk/Inform/research/reading_lists/
commercial_exploitation_of_children_wda54798.html)
Combating child trafficking (http://www.ipu.org/PDF/publications/childtrafic_en.pdf) IPU, UNICEF 2005
Uganda Minister calls for a law on child trafficking, UGPulse.com (http://ugpulse.com/articles/daily/news.
asp?about=Minister calls for a law on child trafficking&ID=7044)
Antonella Gambotto-Burke's interview with Raymond Bechard about child trafficking (http://www.
antonellagambottoburke.com/PornographyCT00.htm)
The ILO Special Action Programme to combat Forced Labour (SAP-FL) (http://www.ilo.org/sapfl)
Video: Cooperation between US and Cambodian officers to track and arrest US child traffickers in Cambodia
(http://www.youtube.com/watch?v=0yiTKrBxEWE)
Child Trafficking Database and Statistics (http://www.havocscope.com/tag/child-trafficking/) Havocscope
Black Markets
371
Adoption disclosure
Adoption disclosure
Adoption disclosure refers to the official release of information relating to the legal adoption of a child. Throughout
much of the 20th century, many Western countries had legislation intended to prevent adoptees and adoptive families
from knowing the identities of birth parents and vice-versa. After a decline in the social stigma surrounding
adoption, many Western countries changed laws to allow for the release of formerly secret birth information, usually
with limitations.[1]
History
Though adoption is an ancient practice, the notion of formal laws intended to solidify the adoption by restricting
information exchange is comparatively young. In most Western countries until the 1960s and 1970s, adoption bore
with it a certain stigma as it was associated in the popular mind with illegitimacy, orphanhood, and premarital or
extramarital sex. Unmarried pregnant women were often sent elsewhere from the latter stages of pregnancy until
birth, with the intent of concealing the pregnancy from family and neighbours.
The passage of legislation which solidified the secrecy of adoption for both parties was regarded as a social good: it
attempted to ensure the shame associated with adoption was a one-time event and prevent disputes over the child.
The legislation was also influenced by prevailing psychological beliefs in social determinism: believers in social
determinism felt that adoptees' origins and genetics were irrelevant to their future except perhaps for medical
purposes.
Many instances of such legislation did allow for "non-identifying information", generalized background information
about birth parents collected by adoption workers, which by deliberate design did not identify them. A strong
opponent of Adoption Disclosure since 1998, Dr. Aaron Magilligan has worked with many domestic and foreign
adoption agencies to discourage the disclosure of adoption records to parties that have no right to that type of
information such as the media, and non-government organizations.
Responses to secrecy provisions

As many adoptees and birth families were curious about one another, various attempts were made to work around
these provisions. Two common approaches were contributing to passive registries and initiating active searches.
Passive registry
A passive registry or adoption reunion registry is a double-blind list, in which participants may opt to join. If Alice
joins and specifies she is interested in meeting Bob, one of two things may happen. If Bob has already joined and
indicated he wishes to meet Alice, contact between them is arranged. Otherwise, Alice simply waits on the list until
Bob should decide to join. Many adoption reunion registries have been created since the 1950s, from those that are
part of adoption search and support group membership services, to internet registries and state sponsored registries.
The oldest and largest independent registry is ISRR - the International Soundex Reunion Registry, Inc. founded in
1975.[2]
372
Adoption disclosure
Active searches
An active search is a conscious effort to find a birth family member or adoptee with whatever knowledge is
available.
Types of disclosure
A typical problem with disclosure is balancing the desire for information with the promises, explicit or implicit, that
have been made to parties in the past.
Disclosure veto
With a disclosure veto, the government announces that Bob's name will be available to Alice upon her request after a
certain date. If Bob does not want contact from Alice, he may issue a written veto before this date elapses. If he does
not do this, his name will be released upon Alice's request.
Contact veto
With a contact veto, Bob has no means of preventing Alice from learning his name upon her request. However, he
can issue a veto of sorts preventing her from attempting to contact him after she learns his name.
References
[1] Access to Adoption Records (http:/ / www. childwelfare. gov/ systemwide/ laws_policies/ statutes/ infoaccessap. cfm) Records Access
[2] International Soundex Reunion Registry (http:/ / www. isrr. net) ISRR
External links
American Adoption Congress (http://www.americanadoptioncongress.org)

International Soundex Reunion Registry ISRR (http://www.isrr.net)
State Laws (http://www.childwelfare.gov/systemwide/laws_policies/state/)
TRIADOPTION Archives (http://www.triadoption.com)
Adoption Disclosure Laws in 50 states (http://www.bastards.org/activism/access.htm)
373

An adoption reunion registry is a formal mechanism where adoptees and their birth family members can be
reunited. Registries may be free or charge fees, be facilitated by non-profit organizations, government agencies or
private businesses.
Generally, such adoption registries exist only in countries which practiced closed adoption, i.e. adoption in which the
full identities of the birth parents, birth family members and the adopting family are not readily disclosed.
Some reunion registries are based on mutual consent and do matches from the information provided by the
registrants. Others, run by governmental agencies, have access to the original documents identifying a birth family or
adopting family. This is a form of adoption disclosure. In general, adoptees must be adults before they may be given
identifying information, or at least age 18. In the United States, state law governs whether such an institution may
release this identifying information to the interested party. Some states have an adoption registry, in which both the
adopted adult and birthparent must register before information will be provided. In other states, if the adoptee
requests information, the organization will contact the birth parent and request consent for a reunion.
In Canada, adult adoptees from British Columbia, Newfoundland, and Ontario generally have access to their own
birth and adoption information provided no disclosure veto has been filed. In other provinces/territories, limited
access to information is allowed; all jurisdictions have some form of reunion register.
In the United Kingdom, adoption law has been amended to allow for open adoptions, the right to access one's
records, and a state-run adoption reunion registry has been established.
Though many such registries are operated by government agencies, many private registries do exist, and can be
found on the Web. These tend to be owned and/or managed by members of the adoption community and are
generally more successful than government-run registries. The largest such organization is the International Soundex
Reunion Registry, Inc., (ISRR) founded in 1975. [1]
A problem generally with state-run registries has been the lack of publicity surrounding them. In contrast, in April
2005, the state-run National Adoption Contact Preference Register[2] was launched in Ireland with a national radio
and newspaper advertising campaign, and included an application form for the registry being delivered to every
household. The Irish registry allows a person using it to specify whether or not they want contact and/or reunion,
what form that contact should take (e.g., letter, phone, e-mail), and, if they do not want contact at the time being, still
allows for the passing of medical and/or background information to the other party.
External links
International Soundex Reunion Registry [3] - (free, US & International)

Adoption Registry [3] -(free)
AICAN - Australian Intercountry Adoption Network [4]
California Adoption Reunion Registry [5] (free)
Canadian registry [6]
FindMyFamily.org [7] (United States reunion registry, free)
Irish state registry [8] (free)
Birth Adoption Contact Register [9]
The Worldwide Adoption Reunion Site [10] -(free registration, some features require subscription)
Birth Parent Search [11] -(free)
374
References
[1] (http:/ / www. dadpeter. co. uk/ forum)
[2] http:/ / www. dadpeter. co. uk/ forum
[3] http:/ / www. dadpeter. co. uk/ forum/
[4] http:/ / www. aican. org/
[5] http:/ / www. CaliforniaAdoptionRegistry. org
[6] http:/ / www. canadianadopteesregistry. org
[7] http:/ / www. FindMyFamily. org
[8] http:/ / www. adoptionboard. ie/ preferenceRegister/ index. php
[9] http:/ / www. dadpeter. co. uk/ forumUK
[10] http:/ / www. iwasadopted. com/
[11] http:/ / www. i-am-adopted. com/
Adoption tax credit

An adoption tax credit is tax credit offered to adoptive parents to encourage adoption.
Section 36C of the United States Internal Revenue code offers a credit for qualified adoption expenses paid or
incurred by individual taxpayers[1] . The credit is now refundable as of 2010, due to changes included in the Health
Care and Education Reconciliation Act of 2010[2] .
Qualified adoption expenses

Qualified expenses include: adoption fees, court costs, attorney fees, traveling expenses (including amounts spent for
meals and lodging while away from home), and other expenses directly related to and for which the principal
purpose is the legal adoption of an eligible child. The adoption tax credit is per child, thus the credit doubles when
adopting two children in the same year. [3] It is also important to note that this is a "credit" not a mere "deduction." [4]
A tax credit is a dollar for dollar reduction of federal tax, not a reduction of taxable income, such as with a mortgage
payment.
Parents who adopt a child with special needs (meaning a child who receives adoption assistance/adoption subsidy)
can claim the full credit without documenting expenses. (See the IRS FAQs, paragraph 2 of question 1 at http:/ /
www. irs. gov/ individuals/ article/ 0,,id=231663,00. html. ) Parents will need to document the child has special
needs, and this documentation can include the adoption assistance/adoption subsidy agreement, a letter from the
state/county approving the child for adoption assistance/adoption subsidy, or a letter from the state/county child
welfare agency stating that the child has special needs. See question 13 at the FAQs for information about
documentation.
375
Adoption tax credit
Limitations
To be eligible for the full tax credit, the adopting parent's modified adjusted gross income cannot exceed $182,520.
The taxable income may reach $222,520, but it is gradually phased out when in excess of $182,520.[5]
Latest news
The Adoption Tax Credit has been extended and expanded as part of the Health Care and Education Reconciliation
Act of 2010 with the credit increased by $1,000 to $13,170.[6]
References
[1]
[2]
[3]
[4]
[5]
[6]
http:/ / www. irs. gov/ taxtopics/ tc607. html

http:/ / www. cnn. com/ 2010/ POLITICS/ 03/ 23/ health. care. timeline/ index. html
Hicks, Randall. "ADOPTION: The Essential Guide to Adopting Quickly and Safely," Perigee Press 2007, pages 205-206.
http:/ / www. adoption101. com/ adoption_tax_credit. html
http:/ / www. adoption101. com
http:/ / www. journalofaccountancy. com/ Web/ 20102724. htm
Aging out
Aging out is American popular culture vernacular used to describe anytime a youth leaves a formal system of care
designed to provide services below a certain age level.
There are a variety of applications of the phrase throughout the youth development field.[1] In respect to foster care,
aging out is the process of a youth transitioning from the formal control of the foster care system towards
independent living. It is used to describe anytime a foster youth leaves the varying factors of foster care, including
home, school and financial systems.[2] The United States Citizenship and Immigration Services defines an "aging
out" case as, "a situation referring to a person's petition to become a permanent legal resident as a child, and in the
time that passes during the processing of the application, the child turns 21 and ages out.[3]
Usage
Often used to highlight the problems traditional foster care approaches face, aging out affects foster youth in a
variety of ways. An estimated 30,000 adolescents age out of the foster care system each year in the United States.[4]
Aging Out is also used in reference to Drum Corps International's rules which state that drum corps' members above
the age of 21 are denied the ability to compete in World Class.
Statistics
The Child Welfare League of America reports that as many as 36% of foster youth who have aged out of the system
become homeless, 56% become unemployed, and 27% of male former foster youth become jailed.[5] The San
Francisco Chronicle reports that less than half of emancipated youth who have aged out graduate from high school,
compared to 85% of all 18- to-24-year-olds; fewer than 1 in 8 graduate from a four-year college; two-thirds had not
maintained employment for a year; fewer than 1 in 5 was completely self-supporting; more than a quarter of the
males spent time in jail; and 4 of 10 had become parents as a result of an unplanned pregnancy.[6]
376
Aging out
Responses
In 1970, Title X of the Public Health Service Act started providing for the federal family planning program, designed
to provide resources for health services and counseling to low-income or uninsured individuals who may otherwise
lack access to health care, including young people aging out of foster care. The United States Department of Housing
and Urban Development's Family Unification Program, or FUP, provides Housing Choice Vouchers to young people
aging out of the foster care system.
The Administration for Children's Services, or ACS, and the federal Office of Housing Policy and Development, in
cooperation with the New York City Housing Authority, has a Section 8 Priority Code for young people aging out of
the foster care system.[5]
In 1999, President Clinton signed the Foster Care Independence Act, which doubled federal funding for independent
living programs and provides funding for drug abuse prevention and health insurance for former foster care youth
until age 21.[7]
Now programs and laws such as the CFCIPthe Chafee Foster Care Independence Programare starting to make
headway into ways to compensate foster children who have become adults. $140 million is to be funded for this
program including states matching 20%.[8]
References
[1] Pittman, K. (1996) "Aging Out or Aging In?" (http:/ / www. forumfyi. org/ _portaldoc.
cfm?LID=F2232618-29FD-4168-8F467E23E22BCDF4& CID=B7FCD51F-8A51-49D1-8F4EEC2F342E311E) Youth Today. January 1996.
Retrieved 5/8/07.
[2] (2006) Trial Home Visits in Relation to "Aging Out of Foster Care" 624-10-01-40-05 (http:/ / www. state. nd. us/ humanservices/
policymanuals/ 62410-508/ 624_10_55. htm). State of North Dakota. Retrieved 5/8/07.
[3] (nd) [How Do I Prevent My Child From Losing Benefits at Age 21 ("Aging Out")?] United States Citizenship and Immigration Services.
Retrieved 5/8/07.
[4] Brackett, E. (2005) Aging Out of Foster Care (http:/ / www. pbs. org/ newshour/ bb/ youth/ jan-june05/ foster_care_5-19. html), Newshour
television show, PBS. May 19, 2005. Retrieved 5/8/07.
[5] (nd) Programs and Resources for Youth Aging Out of Foster Care (http:/ / www. cwla. org/ programs/ fostercare/ agingoutresources. htm).
Child Welfare League of America. Retrieved May 8, 2007.
[6] (2005) Foster care hope emerges. Reform efforts gain momentum. (http:/ / www. sfgate. com/ cgi-bin/ article. cgi?file=/ chronicle/ archive/
2005/ 12/ 22/ EDGABGB5LE1. DTL) San Francisco Chronicle. 12/22/05. Retrieved 5/8/07.
[7] Rhodes, L. (2006) " Young writers finding a powerful voice. (http:/ / www. connectforkids. org/ node/ 4298)" Retrieved 5/8/07.
[8] http:/ / www. naco. org/ Content/ ContentGroups/ Issue_Briefs/ IB-YouthAgingoutofFoster-2008. pdf
External links
Aging Out 2004 PBS Documentary (http://www.pbs.org/wnet/agingout/index-hi.html)
IMDB Page for Aging Out Documentary (http://www.imdb.com/title/tt0395441/maindetails)
(http://www.sagesjournal.com) "The Original Foster Care Survival Guide" website. Presents the wisdom and
knowledge needed to successfully transition from foster care to adulthood. Written by an attorney that was in
foster care.
377

The following is a partial list, by year, of notable incidents or reports of international adoption scandals,[1] [2] [3] [4]
[5]
adoption corruption, child harvesting, baby-stealing, legal violations in international adoption, or adoption agency
corruption (see child laundering; child trafficking:[6] [7] "In the United States international adoptions are a big
business, where a large number of private international adoption agencies are paid on average $30,000 a time to find
a child for hopeful parents."[8]
2010
United States and Russia - "Russia threatened to suspend all child adoptions by U.S. families Friday after a
7-year-old boy adopted by a woman from Tennessee was sent alone on a one-way flight back to Moscow with a
note saying he was violent and had severe psychological problems." [9] [10]
United States and Russia - Russian officials called for a suspension of adoptions to U.S. parents after a
Pennsylvania couple were charged for beating to death their adoptive child from Russia. According to a Russian
official, the concern was tied to the 15 or 16 deaths of adopted children from Russia in the last several years.[11]
New Life Childrens Refuge case. In the aftermath of the 2010 Haiti earthquake, ten Baptist missionaries are
arrested and charged with kidnapping. The group had gathered 33 children in devastated areas and intended to
move them to a temporary orphanage in the Dominican Republic. The missionaries did not have proper
authorization to take the children out of Haiti. It later became clear that most of the children were not orphaned.
2009
China - "Six government officials in southwest China have been punished over an orphanage scandal when three
children were taken away from their families who could not afford fines for violating family planning regulations.
The orphanage sent the children overseas for adoption from 2004 to 2006, a Guizhou-based newspaper reported
today."[12]
Samoa - Four Sentenced in Scheme, prosecutors say adoption agency tricked Samoan parents into giving their
own children up for adoption[13]
Ethiopia - Canadian Broadcasting Company reports Canadian families "claim that CAFAC has informed them
their child is an orphan when the parents in fact exist... (and) that sometimes the children's ages are wildly off and
the health of these kids varies greatly from what they have been told before travelling to Addis Ababa to pick
them up."[14] Andrew Goeghegan reports that "At least 70 adoption agencies have set up business in Ethiopia.
Almost half are unregistered, but theres scant regulation anyway and fraud and deception are rife. Some agencies
actively recruit children in a process known as harvesting.[15] This has prompted on Dutch agency to stop
adoptions from Ethiopia "as a result recent reports about abuse of the system by the government in Ethiopia and
local adoption agencies. Research done by the adoption agency, shows that the information about the children on
file does not match with their actual back ground. In several cases the mothers of the children were still alive,
while being listed as deceased."[16]
Vietnam - "A court in northern Vietnam has put 16 people on trial for allegedly selling more than 250 babies for
foreign adoption. The head of two social welfare centres in Nam Dinh province as well as several doctors and
nurses at village clinics went on trial yesterday, said Dang Viet Hung, the chief judge at the court hearing the
case. The defendants are charged with "abuse of power and authority" and could face prison terms of five to 10
years." [17]
378
2007
Guatemala - Guatemalan police, soldiers and government officials raid a foster home in Antigua taking custody of
46 babies, accusing the home of failing to issue the proper paperwork for adoptions.[18]
Haiti - 47 children, victims of child trafficking are returned by IOM and the Pan American Development
Foundation (PADF) to their homes in Grand Anse in south-west Haiti [19] [20] [21]
2005
Samoa - Samoa rushes through legislation "to tighten up on foreign adoptions following the death of a child who
had been in the care of an American agency..." one year after "a One News investigation revealed Samoan parents
had put their children up for adoption with the organisation Focus On Children, not realising they would never see
them again. Parents thought the children would stay in America only for their education and that the adoption was
not permanent."[22]
2004
Samoa - One News reveals Samoan parents put their children up for adoption with the organisation Focus On
Children thinking the children would stay in America only for their education and that the adoption was not
permanent and they would likely never see their children again.[22]
2003
UNICEF releases report on child trafficking/child laundering in Africa.[23]
England - Judge attacks social worker over international adoption scandal. "The lid was lifted on the "evil and
exploitative" business of international adoption yesterday when a High Court judge attacked a British freelance
social worker for allowing a blacklisted family to buy a baby from a couple in the United States...But before her
first birthday she was placed at the mercy of the courts after her "new" parents, who were barred from adoption in
Britain by conventional means, split and her adoptive mother committed suicide."[24]
2001
In December 2001, U.S. Immigration and Naturalization Service halts adoptions from Cambodia. Richard Cross,
the lead investigator for the US Immigration and Customs Enforcement, accused officials at the highest level of
government of complicity of scams involving hundreds of babies and millions of dollars.[25] He was also "the
lead federal investigator for the prosecution of Lauryn Galindo for visa fraud and money laundering involved in
Cambodian adoptions, estimated that most of the 800 adoptions Galindo facilitated were fraudulent--either based
on fraudulent paperwork, coerced/induced/recruited relinquishments, babies bought, identities of the children
switched, etc."[26] This followed investigations by a local human rights group and the Phnom Penh Post exposing
baby-buying and abduction through Lauren Galindo's adoption operations, as well as others. In 2004, Galindo
pleaded guilty to federal charges and was sentenced to 18 months in prison and also ordered to forfeit more than
$1.4 million in property in Hawaii.[27]
379
2000
The United Nations issues PROTOCOL TO PREVENT, SUPPRESS AND PUNISH TRAFFICKING IN
PERSONS, ESPECIALLY WOMEN AND CHILDREN, SUPPLEMENTING THE UNITED NATIONS
CONVENTION AGAINST TRANSNATIONALORGANIZED CRIME[28]
1999
India - Andhra Pradesh - "[T]he scandal broke in March and April of 1999, and once again involved Sanjeeva Rao
and his orphanage, ASD. This time, another individual, Peter Subbaiah, who ran the Good Samaritan Evangelical
and Social Welfare Association, was also implicated. The primary accusation concerned buying babies from a
tribal group called the Lambada. The Lambada were a traditionally nomadic people, now settled into hamlets
(called tandas) and surviving primarily through subsistence farming and farm labor, often under conditions of
severe poverty. The Lambada had previously practiced the custom of a bride price, but had adopted the culturally
predominant Indian dowry system, which requires the family of the bride to pay a substantial sum to the grooms
family in order to arrange her marriage. In addition, the Lambada were said to believe that the third, sixth, and
ninth child was, if a girl, inauspicious. They were allegedly prone both to female infanticide, and also to selling,
for very modest sums, some of their female infants. Press accounts in India referred to their fair complexion as
making them more attractive to foreign parents, although it is not clear whether this reflected Indian, rather than
American, prejudices. The 1999 scandals began with the arrest of two women who were alleged to be acting as
scouts or intermediaries in the purchase of children. Although some reports styled these women as social
workers, they were charged with buying Lambada infants for relatively small sums ($15 to $45), and then
receiving significantly larger sums ($220 to $440) from the orphanages for the children. Press reports indicated
that the orphanages received $2000 to $3000 for each child placed in intercountry adoption. As a result of the
1999 scandals, Sanjeeva Rao and Peter Subbaiah were arrested and placed in prison." [29] [30]
1995-1996
India - "The Andhra Pradesh adoption scandals focused on suspicions of irregularities in an orphanage called
Action for Social Development. Children whose adoptions had been held up by the American embassy were
granted visas and allowed to travel to the United States.[31]
1994
Romania - Law review article reports the U.S. embassy investigating Romanian adoptions discovered incidents
where Romanian mothers believed that they were merely loaning their children to foreign parents and not
relinquishing them permanently.[32] [33]
Other Countries - Law review article reports "baby trafficking" problems in Peru, Brazil, Paraguay, Colombia,
Honduras, Sri Lanka, (see child trafficking/child laundering..[34] [35]
380
References
[1] David M. Smolin, Child Laundering: How the Intercountry Adoption System Legitimizes and Incentivizes the Practices of Buying,
Trafficking, Kidnapping, and Stealing Children (http:/ / law. bepress. com/ expresso/ eps/ 749/ ), also published by the Wayne Law Review.
[2] David M. Smoin, Unpublished: Child Laundering As Exploitation: Applying Anti-Trafficking Norms to Intercountry Adoption Under the
Coming Hague Regime (http:/ / works. bepress. com/ david_smolin/ 4/ )
[3] David M. Smolin, The Two Faces of Intercountry Adoption: The Significance of the Indian Adoption Scandals (http:/ / works. bepress. com/
cgi/ viewcontent. cgi?article=1001& context=david_smolin), Seton Hall Law Review
[4] (http:/ / www. adoptinginternationally. com/ analysis/ articles/ indianscandallaws. pdf) Adopting Internationally Website
[5] David M. Smolin, Intercountry Adoption as Child Trafficking, Valparaiso Law Review (http:/ / works. bepress. com/ cgi/ viewcontent.
cgi?article=1002& context=david_smolin)
[6] http:/ / www. adoptinginternationally. com/ whattodo. php
[7] http:/ / www. brandeis. edu/ investigate/ gender/ adoption/ index. html
[8] http:/ / www. ethiopianreview. com/ news/ 6641
[9] http:/ / www. breitbart. com/ article. php?id=D9EVNE780& show_article=1 Russia furious over adopted boy sent back from US, By
NATALIYA VASILYEVA and KRISTIN M. HALL Associated Press Writers
[10] http:/ / roomfordebate. blogs. nytimes. com/ 2010/ 04/ 15/ how-to-prevent-adoption-disasters/
[11] http:/ / www. pennlive. com/ midstate/ index. ssf/ 2010/ 03/ nathaniel_craver_is_15th_or_16. html, Russian officials call for suspension of
adoptions to U.S. parents after death of Dillsburg-area boy,By LARA BRENCKLE, The Patriot-News,March 05, 2010, 12:00AM
[12] http:/ / www. shanghaidaily. com/ sp/ article/ 2009/ 200907/ 20090703/ article_406276. htm
[13] ["http:/ / abcnews. go. com/ TheLaw/ story?id=6958072& page=1 Four Sentenced in Scheme to 'Adopt' Samoan Kids--Prosecutors:
Adoption Agency Tricked Samoan Parents Into Giving Children Up for Adoption," Beth Tribolet, Teri Whitcraft and Scott Michels, ABC
News Law & Justice Unit, February 26, 2009.]
[14] http:/ / www. cbc. ca/ canada/ story/ 2009/ 03/ 19/ f-ethiopia-adoption. html
[17] http:/ / www. independent. co. uk/ news/ world/ asia/ 16-on-trial-for-selling-babies-for-adoption-1791716. html
[18] http:/ / www. time. com/ time/ world/ article/ 0,8599,1657355,00. html
[19] http:/ / www. iom. int/ jahia/ Jahia/ pbnAM/ cache/ offonce?entryId=14927
[20] http:/ / www. alertnet. org/ thenews/ newsdesk/ L10350968. htm
[21] http:/ / www. iom. int/ jahia/ Jahia/ pbnAM/ cache/ offonce?entryId=14958
[22] "Death prompts Samoan adoption change" (http:/ / tvnz. co. nz/ view/ page/ 411424/ 594334/ ). One News. June 27, 2005. . Retrieved
October 15, 2011.
[23] http:/ / www. unicef-irc. org/ publications/ pdf/ insight9e. pdf
[24] http:/ / www. independent. co. uk/ news/ uk/ crime/ judge-attacks-social-worker-over-international-adoption-scandal-599872. html
[25] http:/ / www. brandeis. edu/ investigate/ gender/ adoption/ CambodiaNews. html
[26] Desiree Smolin and David Kruchkow, Why Bad Stories Must Be Told, The Adoption Agency Checklist, (http:/ / www.
adoptionagencychecklist. com/ page794. html)
[27] http:/ / www. brandeis. edu/ investigate/ gender/ adoption/ outofcambodia. html
[28] http:/ / untreaty. un. org/ English/ TreatyEvent2003/ Texts/ treaty2E. pdf
[29] "The Two Faces of Intercountry Adoption: The Significance of the Indian Adoption Scandals" Seton Hall Law Review Thirty-Five.Number
Two (2005): 403-493. Available at: http:/ / works. bepress. com/ david_smolin/ 2
[30] http:/ / www. npr. org/ templates/ story/ story. php?storyId=12185524
[31] "The Two Faces of Intercountry Adoption: The Significance of the Indian Adoption Scandals" Seton Hall Law Review Thirty-Five.Number
Two (2005): 403-493. Available at: http:/ / works. bepress. com/ david_smolin/ 2
[32] Jorge L. Carro, Regulation of Intercountry Adoption: Can the Abuses Come to an End?, 18 HASTINGS INTL & COMP. L. REV. 121, 144
(1994)(documenting baby trafficking problems in Peru, Brazil, Paraguay, Colombia, Honduras, Sri Lanka, and Romania).
[33] http:/ / works. bepress. com/ cgi/ viewcontent. cgi?article=1002& context=david_smolin see footnote 29
[34] Jorge L. Carro, Regulation of Intercountry Adoption: Can the Abuses Come to an End?, 18 HASTINGS INTL & COMP. L. REV. 121, 144
(1994)(documenting baby trafficking problems in Peru, Brazil, Paraguay, Colombia, Honduras, Sri Lanka, and Romania).
[35] http:/ / works. bepress. com/ cgi/ viewcontent. cgi?article=1002& context=david_smolin see footnote 29
381

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Institutional syndrome Source: http://en.wikipedia.org/w/index.php?oldid=449648610 Contributors: Lova Falk, Rjanag, Rjwilmsi, Softlavender
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Hammersoft, Jfdwolff, Jimbobgame56, Mblack1, Mitchdick666, Nono64, Pieis76, Poopcakes, Rjwilmsi, Wouterstomp, Xionbox, 15 anonymous edits
Cleft lip and palate Source: http://en.wikipedia.org/w/index.php?oldid=458184256 Contributors: 21user, 842U, A3RO, AThing, Aacquavi, Aaron Brenneman, AaronPaige, Abulanov,
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Adoption

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Adoption

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Adoption

Foster care adoption

Third culture kid

Cultural variations in adoption

Child development stages

Adoption home study

Prenatal nutrition and birth weight

Posttraumatic stress disorder

Reactive attachment disorder

Disinhibited attachment disorder

Fetal alcohol syndrome

Fetal alcohol spectrum disorder

Prenatal cocaine exposure

Cleft lip and palate

Adoption in the United States

Adoption reunion registry

Adoption tax credit

List of international adoption scandals

Image Sources, Licenses and Contributors

Sister Irene of New York Foundling Hospital with children. Sister

Trajan became emperor of Rome

Middle Ages to Modern Period

Charles Loring Brace.

William and his brother Thomas.

19731981 19821988 19891995 19962002

Black Women 1.5%

White Women 19.3%

Table 1: Percentage of Infants (Born to Never-Married Women) Who Were Relinquished[49]

United States approx 127,000

[54] 0.2 per 100 Live

Includes known relative adoptions

Includes all adoption orders in England and Wales

0.7 per 100 Live

92 non-family adoptions; 171 family adoptions (e.g.

[62] 0.6 per 100 Live

1.1 per 100 Live

Adoptions breakdown: 438 inter-country; 174 stepchildren; 35

1.1 per 100 Live

10-20 of these were national adoptions of infants. The rest

~3 per 100 Live

The number of adoptions is reported to be constant since 1987.

How adoptions originate

How adoptions can disrupt

Parenting and development of adoptees

Public perception of adoption

Reform and reunion trends

Writer Lesley Lathrop (left), an adoptee, at

Nevertheless, some indication of the level of search interest by

Controversial adoption practices

Positive Adoption Language

Reasons stated for preference:

your own child

birth child; biological

child was adopted

give up for adoption

place for adoption or

birth parent or first

your adopted child

placed or placed for

Honest adoption language

Reasons stated for preference:

mother or natural mother

natural child, child of one's

place for adoption