Adoption Advocate No. 61Posted Jul 01, 2013
The Healing Power of "Giving Voice"
By: Karyn Purvis, Ph.D. and David Cross, Ph.D.
If she is born into a nurturing family, an infant quickly discovers the power of her voice: she cries, and someone comes to her. Consistently, affectionately, and attentively, her needs are met, and she develops the belief that her cries will bring loving parents intent on meeting those needs. From this basic foundation of care, infants form belief structures that have the power to influence the outcome of their entire lives.
A child without a voice quickly learns he will be “on his own” in getting his needs met. Survival skills emerge in the absence of nurturing care that will later put him on a developmental trajectory of harm. Without a voice, this child will learn not to trust others to care for him. He will lose the capacity to tell his story to safe adults who can guide him to healing. As his capacity for attachment is diminished, he will be unable to ask for his needs to be met. He may learn to use maladaptive survival strategies, such as manipulation, triangulation, control, aggression, and even violence, in order to meet his own needs.
Interventions focused on bringing healing to children who have come from these “hard places” frequently have as a core value, the returning of the child’s voice. Numerous attachment-based interventions teach parents various skills for becoming attentive, responsive, and nurturing in their interactions with their children. Restoring their children’s voices through attentive care frequently becomes the foundation for learning to trust, for healing their histories, for giving up maladaptive survival strategies, and for learning to connect safe, loving attachment figures.
History of Attachment-Based Interventions
Attachment Theory emerged following World War II as a central tenant of child development. Prior to that time it was believed that children simply needed food and shelter in order to thrive. Based on the seminal insights of John Bowlby1, it became clear that without attentive, nurturing caregiving in early life, children could not develop optimally. Among his first publications, 44 Juvenile Thieves2 depicted the histories of young juvenile delinquents in England who were thieves and robbers. Investigations of their early childhood showed disrupted caregiving as a common theme. Others of his era confirmed his findings.3
Although Bowlby’s observations made a clear connection between the absence of early nurturing care and later delinquent behavior, the mechanism was still unclear. Bowlby’s student, and later his colleague, Mary Ainsworth identified parental behaviors which are antecedents of secure attachment. They included behaviors such as: 1) responsive caregiving; 2) acknowledgement of their infant’s cries; 3) affectionate pick-ups; 4) competent holdings; and 5) sensitivity to their infant’s signals (cries, whimpers, etc.). In essence, the relational foundation of attachment consisted of parental warmth, responsiveness and affection. Through studies in Uganda, Ainsworth documented the universality of these parental behaviors as antecedents to secure attachment.4
Later, as a clinical model of attachment emerged, the Attachment Cycle was conceptualized as a continuum of “Needs expressed” (i.e., the infant cries; expressing a need for food, warmth, comfort, etc.) and “Needs met” (i.e., the caregiver comes quickly and consistently to meet both physical and emotional needs of the infant). Babies and young children primarily express needs through crying. Adults who meet those needs responsively, in essence, “give voice” to the developing child. Based on hundreds of iterations of this cycle, Needs expressed/Needs met, an infant develops a working model of human relationships and of themselves. In the context of attentive care and of the giving of voice, this child begins to develop a sense of trust (i.e., “My parents will protect me and meet my needs”), a sense of worth (i.e., “I am precious and my needs matter to my parents”), and a sense of self-efficacy (i.e., “When I cry, someone comes to meet my needs”).
The Loss of a Child’s “Voice”
Disruption of the Attachment Cycle might occur for many reasons – death of a parent, abuse, neglect, trauma, and orphanage care, to name only a few. Among populations of children with disrupted care, many are available for fostering or adoption.
Scientists have long known that when children’s needs are not met consistently during the early days of life, they quit crying – in essence, they lose their voice. In their 1965 book Infants in Institutions5, two Yale University pediatricians, Provence and Lipton, documented the fact that if caregivers did not come quickly and consistently to attend to the cries of infants, the infants would stop crying within a few weeks.
Humanitarian groups entering orphanages after the fall of Ceausescu’s regime in Romania reported large rooms of infants who were eerily silent – not crying because they already recognized no one would come.6 Many reports followed from other international orphanages, describing rooms full of infants who were silent, in spite of being hungry, soiled, and needy. Studies that followed these children after being adopted documented later aberrations in their development and behavior, yielding a profile of increased risk for children whose needs were not met and whose voices were lost in the early days and months of life.7
Through no fault of their own, many of these children and youth develop aberrant survival strategies following the loss of their voices. Control, manipulation, triangulation, aggression, and violence are among the most common strategies. It is only by developing trust and by giving voice that we can empower these children to relinquish such maladaptive survival skills and learn to use words instead of behaviors to get their needs met.
Giving Voice to Children Through Trust-Based Relationship Intervention™
An essential feature of attachment-based interventions is teaching caregivers to respond attentively to the needs of their children – essentially teaching them to give voice to their children’s needs. These interventions document significant improvements in outcomes due to the increase in caregiver attentiveness and insight. Among the most notable attachment-based interventions are Mary Dozier’s ABC program8, Theraplay®9, and Circle of Security.10 Each of these interventions has demonstrated efficacy in changing the attachment relationship between parent and child, and each has demonstrated improved outcomes for children whose parents learned to be responsive to their needs – hearing their voices, and responding affectionately and consistently to their children’s needs.
Another attachment-based intervention, Trust-Based Relational Intervention™ (TBRI)11, has been used in homes12, camps13, schools14, orphanages, and residential treatment facilities15 to great effect. It empowers children and youth and encourages healing through the rediscovery of the power of using their voices.
TBRI data gathered during an annual three-week summer day camp consistently documents a dramatic decrease in problem behaviors paired with a dramatic increase in positive social and attachment behaviors. Children at the camp exhibit significant reductions in depression and negativity on the Child Depression Inventory as well as significant reductions in anxiety, depression, attention problems, social problems, internalizing behaviors, and externalizing behaviors on the Child Behavior Checklist.13 Among the more telling findings, children attending one year’s camp experienced a 19% increase in positive attachment behaviors and a 38% reduction in negative attachment behaviors on the Beechbrook Attachment Questionnaire.
In an unexpected finding after the first summer camp, independent language testing (Comprehensive Receptive and Expressive Vocabulary Test) documented significant advances. Most children experienced improvements in global language, and about 20% of the children experienced an advance of two years or greater in expressive language during the three-week camp. This stunning increase in expressive language can be explained by recent advances in neuroscience, which show a functional connection between the region of the brain for attachment and the region of the brain associated with language. When a child feels safe, connected, and attached, that region activates the regions of the brain associated with language, and the child receives a release of language – a return of his voice. As caregivers learn to give voice to their children, aberrant behaviors decrease dramatically, and positive social and attachment skills emerge – including language competency.
Over a dozen years of summer camp, data has documented the practical release of language for children and youth who tell, for the first time, the stories of their abuse, trauma, and/or neglect, and begin a process of healing. In spite of the fact that many of these children have been in safe, loving homes for years, often they have not used their voices or recognized the healing power of using their voice to tell their stories. Some of these children had “no words,” some used a “wall of words” to push others away, and some used artificial or “baby voices” to get their needs met.
Data from other organizations using TBRI also show a dramatic reduction in negative behaviors as children and youth find their voices and learn to use them appropriately. An interesting pattern emerges in virtually every context, in which violent/aggressive behavior subsides dramatically while verbal aggression initially increases. Initially children use words, but they may be “mouthy” words, requiring us to guide them to use their “good words.” Aggressive words subside swiftly as these youngsters learn that they have voice and will be heard by attentive caregivers.
A recent special issue of Reclaiming Children & Youth published findings from a small-scale study in which TBRI was taught to staff of a residential facility serving high-risk children and youth. This article, “Transforming cultures of care: A case study in organizational change,” reported behavioral incident data from the facility: “Reporting frequency of serious incidents defined as ‘imminent risk and physical aggression,’ serious incidents declined from 187 total incidents in 2010 (prior to training in TBRI) to 116 total incidents in 2011 (following implementation of TBRI). In similar fashion, containments declined from 156 total containments in 2010 to 62 total containments in 2011.”15
Over the years, similar findings have been reported when this trust-based intervention has been used in homes, camps, residential treatment facilities, and schools. TBRI is also elaborated for parents in the book The Connected Child: Bringing hope and healing to your adoptive family.16
Skills and Strategies of TBRI
TBRI teaches both attentive caregiving and specific strategies for restoring voice to children and youth. While a considerable portion of language gains in older children can be attributed to the activation of the brain through caregiver warmth and connection, specific caregiver skills and instructions can also help guide children and youth to regain their voices. Though the skills may seem simple, in sum they are powerful tools to encourage children to use their voices and let go of their protective strategies.
Matching: When a caregiver “matches” body position, voice tone, or activity, they have a connection with their child at an unspoken level. For example, a parent can lower herself into the height of the child to speak, sit quietly in parallel play beside their child, or choose the same dessert or ice cream as their child. In each case, the child feels “felt” and connected. Eye contact, touch, and full attention can also help make a child feel safe, warm, and connected. Knowing there is a platform to be heard sets the stage for children to speak.
Full Attention: Simple as it may seem, giving seconds or minutes of undivided attention forges deep contentment and connection. Some parents set a timer for ten to fifteen minutes a day for undivided time with each child. During that time, they do not answer their phones, work on the computer, or “multi-task” in any way. Their child experiences a deep connection through the emotional availability of the parent. This may be more challenging for families with many children, but a brief moment of full attention accompanied by a promise for more attention later typically meets the needs of a child and encourages him to continue to ask for what he needs, thereby gaining voice. For example, a parent who is busily preparing dinner amidst several children clamoring for attention can look briefly into the eyes of a child, touching his hand or shoulder, and say: “I really want to hear what you are saying, but could we talk right after dinner? I need to finish putting dinner on the table now.”
Giving Choices: Giving a choice can be a powerful tool for helping children practice using their voices and learn how to make good decisions. For example, a parent could spontaneously offer after school one day: “Would you like to do your homework first and then play on the trampoline, or would you rather play on the trampoline first and then do your homework?” This is an attractive invitation for joint problem solving, and invites the child to “use his words” to help make a plan. Another powerful way to use choices is in resolving low-level conflicts or behavioral challenges. For example, in the same scenario, if a child comes home and says, “I’m not doing my homework today!” a parent could respond with the same choices, preceded by something like: “You have to do your homework, but we could have a snack and play on the trampoline first, or we could do homework first and then have our snack and playtime. Which do you choose?” Oftentimes, when given a voice in the schedule, a low-level challenge will dissipate in favor of joint problem solving with the parent or caregiver.
Giving Compromises: In similar fashion, compromises are powerful tools, with dual functions. They can be used simply to empower a child to problem-solve and teach good decision-making through partnership with the parent (by using their voice), or they can be used as a corrective measure to resolve low-level conflicts. For example, when a parent asks her daughter to go to bed, she can learn to ask respectfully: “May I please finish what I’m doing and then go straight to bed?” Many children who become available for fostering or adoption have had little choice in most decisions of their lives. Letting them practice asking appropriately, with their words to have their needs or wants met may also be healing for them.
Sharing Power: Many adults are threatened by the concept of “sharing power.” But this term does not mean capitulating to a willful child, nor does it mean losing power. When used properly, sharing power actually enhances the authority of the adult and, at the same time, helps the child or youth know he is safe with this caregiver, and his needs are being heard. Children and parents naturally share power; for example, a mother may want to eat a hot meal, but if her baby needs her, she is willing to share power, giving up her own plans in favor of the child’s need. A father, likewise, may want to sleep through the night, but if his infant cries, he will share power instinctively, giving up his own desire in favor of his infant’s needs. Remember that by sharing power, parents and caregivers actually prove the power is theirs to share. Sharing power encourages children to use their voices, while at the same time reinforcing that their caregiver is a safe, attentive, authoritative adult.
Using Bridge Activities: Many children are harmed by abusive or neglectful adults before they came into safe, loving homes. Caregivers must find connections that provide a platform for their children to learn they are listening. Observing the child to understand his likes, dislikes, favorite activities, and favorite games will help the caregiver know which activities can be shared regularly in order to create a safe place and time for the child. Rushed or packed days will never provide the safe spaces for children to explore finding their voices and telling their stories.
Using “Magic Feathers”: In the classic childhood tale, the little elephant Dumbo didn’t believe he could fly until he was given a “magic feather” that empowered him to believe in himself and try. For many children, a “magic feather” is a similar tool that gives them courage to try to speak. For example, one child who witnessed his sister’s murder by their mother lost his voice and was unable to talk about the trauma. In our summer camp, he was given a walkie-talkie and was allowed to hide in a tent or behind a tree and tell his story to an adult listening on the other walkie-talkie. As he gained courage, he was able to share his story freely – and his healing could begin.
The gift to speak and to be heard is the birthright of every child. Biology prepares parents to give this gift and prepares children to receive it. Tragically, too many children do not come from homes or situations in which the adults are able to love them and give them voice. Because of their histories, these children and youth must be taught they have a powerful gift – a voice – and that they also have caregivers who want to listen and understand their words and their needs. Purposeful, deliberate parents and caregivers can restore this lost gift of voice and, in so doing, begin to provide connection, trust, hope, and healing for these children who have come from difficult places.
- John Bowlby’s foundational work on Attachment Theory.
- Bowlby, J. (1951). Maternal care and mental health. Geneva: WHO Monograph 2.
- Bowlby, J. (1969). Attachment and loss, Vol. 1: Attachment. New York: Basic Books.
- John Bowlby’s initial observations of juvenile thieves.
- Bowlby, (1944). “Forty-four juvenile thieves.” International Journal of Psychoanalysis, 39: 19-52, 107-128.
- Contemporaries of John Bowlby whose insights were consonant with his developing theory about the impact of absence of nurturing care during early development.
- Goldfarb, W. (1944). The effects of early institutional care on adolescent personality. Journal of Experimental Education, 12, 106-129.
- Goldfarb, W. (1945). Effects of psychological deprivation in infancy and subsequent stimulation. American Journal of Psychiatry, 102, 18-33.
- Spitz, R. A. (1945). Hospitalism: An inquiry into the genesis of psychiatric conditions in early childhood. The Psychoanalytic Study of the Child, 1, 53-73.
- Spitz, R. A. (1956). The influence of the mother-child relationship, and its disturbances. In K. Soddy (Ed.), Mental health and infant development (Vol. 1). New York: Basic Books.
- John Bowlby’s student, Mary Ainsworth, later became his colleague in the ongoing development of Attachment Theory.
- Ainsworth, M.D.S. (1967.) Infancy in Uganda: infant care and the growth of love.Oxford, England: Johns Hopkins University Press.
- Provence and Lupton, two Yale pediatricians, published outcomes among institutionalized infants, noting that they lost their voice within a short time without consistent, nurturing care.
- Provence, S., & Lupton, R. C. (1962). Infants in institutions. New York: International Universities Press.
- Numerous humanitarian groups have reported the eerie silence among infants in institutions. A few are listed here:
- Fishbein, M. M. (1992). Physicians discuss experiences of Romanian visit. AAP News, pp. 8, 12-13.
- Johnson, A. K. & Groze, V. (1993). The orphaned and institutionalized children of Romania. Journal of Emotional and Behavioral Problems 2(4), 49-52.
- World Vision (1990). World Vision Annual Report. Pasadena, CA: World Vision. Zeanah, C. (2000). Handbook of Infant Mental Health (2nd. Ed.). New York: Guilford.
- Outcomes for children and youth whose needs were not met during early days of development are well documented. A few notable studies are listed here:
- Ames, E. W. (1997). The development of Romanian orphanage children adopted to Canada. Human Resources Development Canada: Final report.
- Bakermans-Kranenburg, M.J. Steele, H., Zeanah, C. H., Muhamedrahimov, R. J., Vorria, P., Dobrova-Krol, N. A., Steele, M., Van IJzendoorn, M. H., Juffer, F., & Gunnar, M. R. (2011). Attachment and emotional development in institutional care: Characteristics and catch-up. In R. B.
- McCall, M. H. van IJzendoorn, F. Juffer, C. J. Groark, and V. K. Groza (Eds.), Children without permanent parents: Research, practice, and policy. Monographs of the Society for Research in Child Development, 76(4), 62-91.
- Cross, D. R. & Purvis, K. B. (2008). Is maternal deprivation the root of all evil? Special issue: Nurturing Human Nature, Advances in Latin American Psychology, 26(1), 66-81.
- Fisher, L., Ames, E. W., Chisholm, K., & Savoie, L. (1997). Problems reported by parents of Romanian orphans adopted to British Columbia. International Journal of Behavioral Development, 20(1), 67-82.
- Gunnar, M. R. (2001). Effects of early deprivation. Findings from orphanage-reared infants and children. In C. A. Nelson and M. Luciana (Eds.) Handbook of developmental cognitive neuroscience, (pp. 617-629).Cambridge, MA: MIT Press.
- Marcovitch, S., Cesaroni, L., Roberts, W., & Swanson, C. (1995). Romanian adoption: Parents’ dreams, nightmares, and realities. Child Welfare, 74, 993-1017.
- McCall, R. B., van IJzendoorn, M. H., Juffer, F., Groark, C. J., & Groza, V. K. (Eds.). (2011). Children without permanent parents: Research, practice, and policy. Society for Child Development Monograph, 76(4), 1-138.
- Morrison, S. J., Ames, E. W., & Chisholm, K. (1995). The development of children adopted from Romanian orphanages. Merrill-Palmer Quarterly, 41 (4), 411-431.
- Verhulst, F., Althus, M., & Verslluis-den Bieman, M. (1990). Problem behaviour in international adoptees – I and II. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 94-111.
- Zeanah, C. (2000). Handbook of Infant Mental Health (2nd. Ed.). New York: Guilford.
- Mary Dozier and her colleagues have developed an intervention primarily targeted at teaching parental sensitivity to children’s cues.
- Dozier, M., Albus, K., Fisher, P. A., & Sepulveda, S. (2002). Interventions for foster parents: Implications for developmental theory. Developmental Psychopathology, 14, 843-860.
- Dozier, M., Higley, E., Albus, K., & Nutter, A. (2002). Intervening with foster infants’ caregivers: Targeting three critical needs. Infant Mental Health Journal, 23, 541-554.
- Theraplay and Theraplay for Groups are dynamic therapeutic modalities, that teach parents sensitivity to their children, and teaching them playful ways in which they can connect.
- Jernberg, A. M., & Booth, P. B., (1998). Theraplay: Helping parents and children build better relationships through attachment-based play (2nd ed.). San Francisco: Josey-Bass Publisher.
- Rubin, H. B., & Tregay, J. (1989). Play with them: Theraplay groups in the classroom. Springfield, Illinois, 1989.
- Circle of Security has demonstrated dynamic outcomes for high-risk parents and their children. Marvin, R., Cooper, G., Hoffman, K., & Powell, B. (2002) The Circle of Security project: Attachment-based intervention with caregiver-pre-school child dyads. Attachment & Human Development. Vol. 4(1).
- Hoffman, K., Marvin, R., Cooper, G. & Powell, B. (2006). Changing toddlers’ and preschoolers’ attachment classifications: The Circle of Security intervention. Vol.74(6), 1017-1026.
- TBRI is a holistic intervention that can be taught and used in any environment. It is rooted in attachment theory and teaches caregiver insight and sensitivity. For an overview see:
- Purvis, K.B., Cross, D.R., & Pennings, J. S. (Winter 2009). Trust-Based Relational Intervention: Interactive Principles for Adopted Children with Special Social-Emotional Needs. Journal of Humanistic Counseling, Education and Development, 48(1).
- For very high-risk children, parents can be taught in the home how to connect and nurture their children, while teaching appropriate life-skills (for example “using words”.)
- Purvis, K.P., McKenzie, L. B. & Cross, D. R. (Under review.) A trust-based intervention for a young child diagnosed with Bipolar and Attachment disorders. Journal of Early Intervention.
- The Hope Connection is a camp for children who are adopted or fostered. Dramatic data each summer document the power of an attachment-based environment that gives voice.
- Purvis, K. B., Cross, D. R., Federici, R., Johnson, D., & McKenzie, L. B. (Winter 2007). The Hope Connection: A therapeutic summer camp for adopted and at-risk children with special socio-emotional needs. Adoption & Fostering, 31(4), 38-48.
- Purvis, K. B. & Cross, D. R. (2006). Improvements in salivary cortisol, depression, and representations of family relationships in at-risk adopted children utilizing a short-term therapeutic intervention. Adoption Quarterly, 10(1), 25-43.
- Purvis, K. B., Cross, D. R., Paris, S., Harlow, J. & Milton, H. under review). Creating a trauma informed environment in an elementary school: Implementation of Trust-Based Relational Intervention School Mental Health.
- Purvis, K. B., Cross, D. R., & Pennings, J. S. (2007). International adoption of post-institutionalized children: Implications for school counselors. Journal of School Counseling, 5(22). Retrieved December 3, 2007, from http://www.montana.edu
- Purvis, K., Cross, D., Jones, D. & Buff, G. (2012). Transforming cultures of care: A case study in organizational change. Reclaiming Children & Youth.
- Purvis, K.P., McKenzie, L. B., Kellermann, G., Cross, D. R. (Winter 2010). An Attachment Based Approach to Child Custody Evaluation: A Case Study. Journal of Child Custody. 7(1), 45-60.
- A resource for understanding the complex constellation of behavioral, emotional, cognitive, and attachment behaviors frequently exhibited by children and youth who come from the “hard places.”
- Purvis K. B., Cross D. R. & Sunshine W. L., (2007). The Connected Child, New York: McGraw Hill.