I first started administering psychological testing to foster and adopted children in 1992. I had just completed my training in child psychology, with much of this focused on the assessment of children's psychological status. As would be expected, I identified high rates of depression, posttraumatic stress, and anxiety in the children I assessed. Many of these kids had found their way into temporary or permanent homes without ever having been provided with a context or adequate explanation as to how and why this happened. Some were grieving for birth families--whether they actually knew or remembered them or not--and most of these kids felt they had to shed one identity and assume another. Training for foster and adoptive parents was pretty weak back then, and services directed toward this population of children was practically non-existent, even in the Bay Area of California where I did my training.

As our understanding about the psychology of foster care and adoption has grown over the years, we now have a better grasp on the role attachment plays in a child's development. Increasingly, we are also coming to appreciate that the psychological treatment of children yields better results when it is provided in a family context, rather than just meeting alone with the child week after week. With respect to psychological testing of foster and adopted children, more of them are being referred for this service, as families and providers appreciate the part it plays at pin-pointing aspects of the child's overall functioning and development.

In the years I have been conducting psychological testing with foster and adopted children and adolescents, certain themes have emerged. Many of these kids, for example, are immature relative to their peers. This makes sense on one level, in that it is not uncommon for children in the child welfare system to experience disruptions in basic aspects of their psychological development. While other kids their age were playing and attending the to the task of being a youngster, for example, many of these kids directed their attention to basic survival. Maybe they grew up in a household where there was abuse, neglect, substance abuse, domestic violence, or impoverished conditions. When this happens, children can't direct their efforts to age-typical activities such as play, as they are more focused on the immediate safety and well-being of themselves and perhaps those around them. Similarly, if a young child spent her early months or years in an orphanage, the hope of getting simple needs met and attended to likely consumed a good deal of her internal world.

In the assessments I conduct of foster and adopted children, I also find high rates of intellectual and neurological delays. This isn't too surprising in some respects, given that parents don't typically seek my services unless their child is presenting with ongoing emotional, behavioral, or learning difficulties. Though blanket statements can rarely be made about any group of people, foster and adopted children are at higher risk for manifesting developmental delays given the circumstances and reasons that result in them living apart from their birth parents. Put simply, poverty, poor prenatal care, prenatal exposure to toxins (alcohol, drugs, tobacco, or lead), premature birth, birth trauma, and/or post-birth neglect, abuse or trauma takes a toll on a child's neurological and physical development. Certainly, these effects won't look the same in all children, but it is a mistake to ignore the implications.

Despite all the advances made in medicine, babies born eight or more weeks early, as well as those who were exposed to toxins in-utero, remain at risk for many mental and neurological problems, including visual, hearing, and motor deficits, poor emotional regulation, attention problems, and language delays. For example, by grade school, children who weighed less than four pounds at birth--most of whom were born premature--perform more poorly in school and score about six points lower on IQ tests than children born full term. As Daniel Siegel points out in his book, The Developing Mind (1999), trauma and neglect in early childhood can actually inhibit adequate growth of the brain: "...early life history of absence of any attachment experience (as in severe neglect) or the experience of overwhelming trauma (as in physical, sexual, or emotional) may markedly alter the neurobiological structure of the brain in ways that are difficult, if not impossible, to repair." Thus, a child's behavior, personality, and brain functioning is not just influenced by attachment, but by biology, genetics, and life experiences.

Alcohol

With respect to alcohol and drug use during pregnancy, the results are very concerning. Prenatal alcohol exposure is one of the leading causes of mental retardation, and it readily crosses the placenta. Thus, if a mother is intoxicated, her fetus is drunk as well. In addition, alcohol directly kills neurons in fetal brains.

Marijuana

Marijuana use offers the double-whammy of a drug effect and the oxygen deprivation caused by smoking. THC, the intoxicating chemical in marijuana, crosses the placenta and is cleared very slowly from the fetal circulation. Like tobacco, marijuana greatly increases carbon monoxide levels in the fetus' circulation, robbing the developing brain of necessary oxygen. Maternal marijuana use has been linked to altered visual and startle response in newborns, to behavioral deficits in school-aged children, and to verbal and memory deficits in toddlers.

Cocaine

Cocaine does not produce any particular pattern of fetal malformation, but it is associated with gestational problems that interfere with normal brain development. Babies of cocaine-addicted mothers tend to be small, whether or not they were born prematurely. After birth, cocaine-exposed babies don't respond well to their environment or interact normally with caregivers.

Cigarettes

Whereas society ranks drugs from 'okay' (cigarettes) to 'not okay' (cocaine), the impact these substances has on the developing fetus is the opposite of what would be expected. Many children born exposed to cocaine or heroin, for example, do not present with noteworthy physical or psychological complications. When a mother smokes, however, the effects can be quite significant. When a pregnant mother smokes, nicotine rushes into the fetal circulation and dramatically alters the baby's breathing movements, with periods of apnea. Several long-term studies of children born to mothers who smoked during pregnancy have suggested that their brain development and function are compromised. In various reports, prenatal smoking has been linked to deficiencies in newborn sucking ability, in language and motor skills in infants, in hyperactivity and auditory attention in young children, and in learning ability in school-age children. In studies of animals and children, prenatal exposure to tobacco contributes to behavioral deficits, which can present as ADHD, oppositional and defiant behaviors, and poor emotional regulation.

Implications

Unfortunately, I don't believe that adequate attention is directed by many professionals toward the child's prenatal experience in the course of conducting an interview or assessment. In addition, it is not uncommon for me to read reports by my colleagues where no tests of cognitive ability or function were administered. While this might be permissible in some instances, I firmly believe that the assessment of all foster and adopted children must include some measure of cognitive functioning. Otherwise, there is a tendency to attribute all of the child's difficulties to attachment or psychological factors. While these attributes are important, the magnitude of brain compromise I see with this population of children points to the importance of broadening the nature of interview questions and testing procedures that should be integrated into child assessment.

When an adequate assessment is conducted, and if neurological vulnerability or compromise is shown to be present with a particular child, this has significant implications with respect to treatment. If a child is having problems at home or school solely because of emotional factors, family counseling and perhaps short-term use of psychotropic medication may be indicated. If a child's struggles are due to neurological reasons, however, it can be a set-up for parents, teachers, and the child himself to rely upon charts, rewards, positive reinforcement, and expectations of self-control. Think of a situation where an adult has a head injury or suffers a stroke. We might find the behaviors and personality changes that result from this problematic, but we usually have realistic expectations with respect to issues of change and recovery. By ignoring the part a child's brain plays in their behaviors or emotions, we deny them this respect.

Too often, parents and providers expect that psychiatric medication will tackle and address the emotional and behavioral problems of children in their care. Whether the brain is compromised or not, this is simply unrealistic. Take the example of a person with diabetes. The use of medication with diabetes can be helpful, but in most instances, simply using drugs alone will not help the person gain control of their condition. Instead, they must also pay attention to diet, exercise, and other health factors.

There are a variety of reasons why a good number of foster and adopted children are prescribed drugs. First, ours is a society that wants to believe there is a pill for almost any condition; second, insurance providers would much rather pay for the cost of a psychiatric consultation and a prescription than for more costly interventions such as inpatient treatment, intensive psychotherapy, or neurological rehabilitation; third, many foster and adoptive parents will tell you that the behavior their child manifests is simply bizarre, if not outright dangerous. This can include lying, stealing, fire play, animal cruelty, sexual precociousness, violence, dare-devil acts, and self-injury. When parents witness this, they desperately need an intervention that will help calm or settle the problematic behaviors. The thought of waiting weeks or months for therapy to 'kick in' isn't an option, and thus, medication is often requested.

There are certainly instances where medication can be useful with children. When the child's behavioral and emotional struggles are due to brain compromise, however, medication may have limited effects. Instead, brain compromise requires a variety of proactive efforts on the part of the parents, which often includes intensive advocacy for their child, particularly in school. Sadly, this isn't what many parents are prepared to hear, and especially in instances of foster care, the care provider may not believe it is their responsibility to work so hard at trying to manage or redirect the child's actions. As I have written elsewhere, some adoptive parents have attempted to sue the agencies that placed the child in their care, citing the unanticipated medical, psychological, and educational costs associated with raising a child they weren't told had special needs.

Interventions

No book or article can offer the right answers for each possible situation that can arise in the day-to-day life of a child. Instead, parents can learn ways of being with their children that promotes the development of empathy and compassion, while also affording opportunities for social, emotional, and academic success. The following suggestions are those I have found to be most useful with the clients and families with whom I work:

1. Learn about your child's condition. Make sure she receives a comprehensive assessment, which includes psychological and cognitive testing. If one has not been completed within the past year or two, request an updated one.

2. Many children with brain compromise have noteworthy deficits in the areas of short-term memory and attention. Regardless of their age, only offer one directive at a time and do it at eye level. If necessary, ask the child to repeat back what you asked. Only ask the child to assume responsibility for things they can realistically do.

3. Brain compromise, as well as psychological variables, can affect a child's emotional age. Don't belittle the child, but try relating to them at their emotional, not chronological age. They will feel less confused by what you say, and they will find your words more supportive. You will also experience less frustration if you recognize that your 14-year-old really functions closer to that of a six-year-old; would you ask a six-year-old to clean their room without offering proper supervision and assistance?

4. Meet with teachers and explain what is going on with your child. They do not need to be provided with extensive details about the child's history--especially if they reside in foster care--but let the teacher know what to anticipate behaviorally. Share with the teacher the strategies you have found to be effective at anticipating, redirecting, or managing the child's behavior. Also, make sure your child is in the right class. Some kids simply need a more experienced teacher or even an adult male teacher in order to do well. It is not fair to the teacher, the other students, or your child to maintain him in a class where his needs cannot be addressed.

5. The Individuals with Disabilities Education Act of 2004 [www.idea.ed.gov] mandates early intervention services for special needs kids. This includes psychological and social work services, speech and language services, occupational and physical therapy, special education programs, in-home living assistance programs, and transportation services. Especially in small and rural communities, the school may fight you to the end on this one. It costs them money and resources, which they will tell you they don't have. If necessary, consult with or hire an attorney.

6. Try 'brain-strengthening' exercises. This can include the use of logic puzzles, which can be found in the bookstore (in the Game section) or on-line. Also, ask your child to explain their understanding or rationale for easy and complex decisions (e.g. "Why do we ask kids not to talk to strangers?" "Why do we give you chores?"). Gradually shape their comprehension of social concepts.

7. Encourage all providers to collaborate with each other. Too often, the therapist doesn't talk to the psychiatrist; the psychiatrist doesn't talk to the teacher; the school social worker doesn't talk to the parents.

8. As the child grows older, focus more on adaptive functioning. When he is a teenager, your child can get away with having poor math or reading skills. Unless he can take care of basic needs, however, he'll be unable to live independently. Don't wait until he is 16 to address these matters. Identify the goals and make sure the school works with you at shaping these.

9. Only place the child in therapy that takes into account her cognitive, social, and physical functioning. Too often, these kids are enrolled in 'talk therapy,' which may not do much good, given its focus on asking the child to reflect on their behaviors or life.

10. Talk with other parents whose children have similar behaviors or conditions. They often have useful tips, and if nothing else, the support they offer is valuable. Taking care of a child with brain compromise--either on a short- or long-term basis--is extremely trying. You need to have adequate support in order to help you recognize which actions the child has control over, versus which ones he doesn't. Too often, parents of these kids think the behaviors are deliberate, when in fact, the child has no conscious control over them.

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