Tag Archives: orchids and dandelions

“Silly” Behavior

What do people mean when they refer to a child as “acting silly”? Usually they mean that the child is laughing or smiling, giddy. This is a wonderful part of childhood—the freedom to be gleeful. Other times, though, it can mean acting like a clown, for example to gain peer attention. This is frustrating to teachers, because a student’s “silly” behavior is usually disruptive to her class. Typically, it will be hard to get the child’s attention. Teachers and parents express frustration with the child’s behavior and report multiple attempts to correct the child verbally. Sometimes verbal corrections work. Often they do not.

The reason verbal corrections fail to work depends in part on the child’s state of regulation. If the child is a little giddy, he will usually consider the positive consequence of complying with the adult’s redirection—and the negative consequence of not complying– and will settle down. If a child is significantly dysregulated, he isn’t processing auditory information in an efficient way, and it will be hard for him to “hear” the teacher; he will also have a harder time using his higher level cortical thinking to “think things over” and change his behavior.

In addition, children learn patterns of behavior—first at home and then in school and with peers. A child’s ability to self-regulate and negotiate power and authority begins with his family relationships. This does not mean that parents cause the problem, but it does mean that their response to their child’s noncompliant behavior plays a role.

The child’s temperament also plays a role. A sensitive “orchid” child will be less resilient to the stress caused by an adult’s demands. Most of these demands require a transition from the child’s current activity and the state of regulation he is experiencing in the moment, to a different activity and a disorganization and reorganization of regulatory state. For example, a parent’s request that the child stop playing and come to the dinner table requires a whole set of sequential transitions that include changes in emotion and regulatory state. An “orchid” child will have a much harder time managing all these transitions than a “dandelion” child.

There are many factors involved in a child’s “silliness”. I think most problematic silliness is related to difficulty with self-regulation at some level. If that is indeed the case, getting through to a “silly” child means helping the child become more regulated. That will often mean separating him from the group to help diminish the overstimulation of his peers’ attention. When he is calm, it as usual helps to talk the situation through with him.

More About Orchids

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I am interrupting my blog progression again to talk about a recent infant parent mental health weekend, while it is still on my mind. We heard two terrific lectures last month about temperament and attachment, both subjects of particular interest to me.

The lecture on temperament was again given by Nancy Snidman, the temperament researcher. Nancy defines temperament as “predisposition to respond to the environment in certain ways”. There are many terms to describe temperamental characteristics – for example, introversion and extraversion, fearfulness, sociability, rhythmicity, thrill and adventure seeking, thoughtfulness or empathy, and many more.

One of the most important dialectics is the relationship between temperament and environment. In this case, temperament refers to inherited characteristics and the environment refers to experiences with family, friends, school, and life events. Nancy pointed out that there has been a long history of ways of thinking about temperament. In classical times, the Greeks and Romans thought of temperament in terms of the “humors”. In the 18th century, John Locke deemphasized temperament in favor of the influence of the environment, but then in the 19th century, Darwin focused on the importance of heritable factors in his evolutionary theory. The post World War II period again attributed the most powerful influence to the environment, for example in Freudian theory that gained widespread popularity. However, current research, such as in genetics and neuroimaging, has brought us back to a focus on temperament. Luckily, contemporary theories generally maintain a complex perspective by also including the important influence of the environment.

Some of the variables used by Nancy in studies of temperament deriving from Rothbart infant behavior questionnaire include approach, sadness, activity, perceptual sensitivity, fear, soothability. For example, does the baby get excited when given a new toy (approach), or how sad does the baby get when the caregiver goes away, is the baby easily soothed, does the baby enjoy cuddling?
Nancy reported on a longitudinal study of two styles of temperament – behaviorally inhibited (shy, wary of novelty, slow to approach), and behaviorally uninhibited (sociable, comfortable with novelty). They measured the time it took 31-month old children to accommodate to various novel situations, such as the time it took for them to enter a toy cloth tunnel, the time it took them to approach a robot. Some children behaved in relatively “inhibited” ways, and others were significantly less inhibited. The researchers wondered where this “shy” and “outgoing” behavior was coming from.
Starting with the hypothesis that people have different thresholds of excitability in the amygdala that create different sympathetic nervous system responses, resulting in different kinds of behavioral reaction to uncertainty, Nancy’s research team designed various kinds of auditory, visual, and olfactory stimuli to activate their amygdalas and test their hypothesis. In the lecture, Nancy showed films of 4-month old babies in the experimental situation. The babies were seated in a baby seat, and first one mobile figure was waved in front of him and then another, and then three at once. The first baby sat, attentively watching the moving figures, moving his fingers slightly, calm. The second baby started to fuss as the level of stimulation increased until he arched his back and began to scream. The experimenters studied the frequency and direction of every arm and leg movement, negative vocalization, arched back, etc. The babies sorted themselves out into high reactive babies with “high motor/high cry” and low reactive babies with “low motor/low cry”. Then they studied a group of children from 9-months to 15 years, to see what happened to them.
They were thinking of reactivity in terms of biology. If the amygdala fires, there is sympathetic nervous system activity – arousal, heart rate, respiratory rate. They believe that the biology of the children has a direct effect on their behaviors. If the amygdala is firing and the sympathetic nervous system is “Go!” it will produce behavioral responses. The hypothesis was that the babies who at 4 months were high reactive (high motor/high cry) by 2 ½ years became shy children, and that was because they had inherited a temperament associated with a low threshold of reactivity in the amygdala. These children were what I have referred to previously in the blog as “orchids”.
Across the years, they measured the children’s behavioral and physiological responses – at home at school, and in the lab – to situations that challenged them with different types of novelty or uncertainty. They found that the children moved from simple high reactivity in the youngest babies to a mixture of reactivity and shyness, or inhibition, in the older babies. This shift from high motor activity and high vocalization, to inhibition in the older infants reflects what we know about adults. In some high reactive older infants, when the experimenter changed the tone of her voice from pleasant to harsh as she invited the child to touch a toy, the child withdrew. Over the years, the researchers found remarkable consistency in the reactive style of the children. Some of the high reactive children became less shy, but the uninhibited children did not change. Interestingly, when the high reactive children became comfortable in their environments, they did OK. It was the transitions that are the problem. The high reactive children had more trouble with transitions.
The researchers concluded that there is “strong evidence that infant reactivity is related to a predisposition to have an excitable limbic system” and that this kind of reactivity is a “stable quality over time and situation” (Snidman, 2014). In addition, the research suggests that though these biological factors do not determine anything about the child’s future, and that environment can have an important influence on the child’s behavior and personality characteristics, these biological constraints remain as part of the child’s inherited predisposition.
From my point of view as a clinician, I would stress the value in helping parents understand their children, and teachers understand their pupils, so that they can take the children’s temperament into account when they make expectations of them. Children of all temperaments may be able to achieve the same accomplishments, but they may require different degrees and different types of support in order to achieve them. Earlier blog postings include information related to this subject.

photograph by Ginger Gregory

Snidman, Nancy, “Temperament: Importance, Influence, Impact”, Lecture given at Infant-Parent Mental Health Program, U Mass Boston, Sept. 19, 2014.

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The Challenge of Making Transitions

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Just before I left on vacation, a mother of a child in my practice asked me why it was so hard for her 6-yo son to make transitions. I was rushing to get ready to leave, so I sent her a quick email promising to respond more fully when I had a chance to think about it. I have had her question in the back of my mind and was especially struck by it when I arrived in Europe and experienced jet lag. It occurred to me that jet lag was a good metaphor for the kind of transition the mother was asking about.

First of all, her child is one of those highly sensitive children I refer to as “race horses”, of others in the literature have called “orchids”. He is extremely intelligent but sometimes retreats to infantile behavior patterns, and he often reacts with extreme distress in the context of transitions – even simple daily transitions such as getting up and getting ready for school in the morning or leaving play to go somewhere or do something else. This problem is interesting because it gets mixed up with all sorts of other categories of problems – such as problems with compliance (behavior problems) or sensory over-responsivity problems (SOR) (Ben-Sasson et al, 2010).

I think there are reasons for this confusion.As writers on “orchid” children point out, it is easier for children with certain temperamental characteristics to readjust to changes in their environment. (I chose the above photo of young Indian dancers because I imagined – though I do not know these children – that the girl on the left has an easier temperament than the girl on the right.) These delicate children are often much harder to parent than children with easier or more resilient temperaments (“dandelions”), and parents and child often initiate problematic interaction patterns early on that can influence the child’s developmental trajectory in an unfortunate direction. It then becomes the job of the child therapist to help the family (child and parents) correct this misdirection.

The kinds of problematic patterns that are characteristic of this situation typically involve mutual over-control. That is, children who feel highly stressed by demands for change (in other words, transitions) often try to exert a counterbalancing force by controlling their environment (their parents, included). Parents may respond either by engaging in a control struggle with the controlling child or by giving in, or by both (Granic, 2006). When these patterns are repeated, they become more firmly rooted in family behavior. I refer to this as building stronger infrastructure for the problem cities (metaphor for problematic relational patterns such as struggles in families) so that it is easier to get there and stay there. Of course, it is better for all involved to build strong infrastructure for the cities that represent more adaptive behavior patterns such as collaboration, but when people are stressed, they often choose the behavior that takes less energy (from the point of view of managing emotions and using reflective capacity) in the short run and more energy in the long run (having to repair the ruptures that struggles and fights cause in the family).

The job for child therapists is to work with child and family to “break the habits” of the problem behaviors and substitute more adaptive patterns. This is done by a variety of techniques including gaining insight into the meanings underlying the behavioral reactions of child and parents and supporting the emotional regulation of all concerned, and then … practicing the new more adaptive patterns again and again and again. I will write more about this important aspect of the topic in a future posting, but I will limit myself here to the mother’s question of “why?”

Let me return to the metaphor of jet lag. My intention is not only to respond to “why” a child has trouble with transitions, but also to offer a way of empathizing with the irritable child. (Often, a parent empathizing with the child allows her or him to better imagine the child’s mind and this can facilitate the parent’s choice of response to the child’s demanding or oppositional behavior). I found a good article on jet lag that describes it in terms of whole organism dysregulation (Vosko et al, 2010). Circadian rhythm – sleeping longer at night and less during the day – is one of the first organizations to emerge in the developing newborn (Sander, 2008). It is achieved through a series of oscillatory networks that include a master oscillatory network in the suprachiasmatic nucleus (SCN) in the brain and also sensitivity to environmental light cues (Vosko, p. 187). During jet lag, the paper continues, abrupt changes in the environmental light-dark cycle desynchronize the SCN from downstream oscillatory networks from each other, disrupting sleep and wakefulness and disturbing function (ibid, 187). This kind of “circadian misalignment” can lead to a series of symptoms, including major metabolic, cardiovascular, psychiatric, and neurological impairments (ibid, 187). During this trip, as usual, my jet lag “took over”. Although I intended to stay awake and enjoy the company of my friends and the new landscape, I was compromised in my ability to do so. The feeling of dysphoria came in waves; sometimes I felt my old self again and other times I felt tired, irritable, and even sick.

The benefit of this metaphor is that it emphasizes the notion of whole human being “organization”. Many problematic behaviors result from a disorganization of adaptive patterns of functioning. The human organism is constantly working to keep itself on track and to accommodate small bumps and disruptions. It is when the reorganization does not happen smoothly, when things fall apart, that a “symptom” appears. The symptom can be physiologic as well as emotional, just as in jet lag. Children who have delicate temperaments or other developmental reasons for high sensitivity (such as children with ASD, uneven development, trauma, or SOR) are particularly vulnerable to this problematic disorganization.

Consider all the demands for reorganization that a child has to respond to on a daily basis: She has to wake up, changing from a sleep state to an alert state. She has to get up and get ready for school, requiring many transitions from the multiple small tasks involved in washing and dressing. She has to eat breakfast, even if she is not hungry at the time. She has to say goodbye to home and parents and make a big shift from a relatively dependent position to a more autonomous position in terms of initiative and compliance. When she gets home from school she has to deal with other important transitions. Don’t think for a moment that greeting a beloved parent is necessarily going to be a pleasant experience; the transition from a holding-it-together-at a higher-level-of-organization-state at school to a more relaxed and dependent one at home is often bumpy! In addition, often parents of sensitive children give them aids to help them keep organized in the transition, such as video games. As I have mentioned in another posting, these games work very well to keep a child organized because they provide an effective external regulator. When this external source of regulation is taken away abruptly, it can be expected to cause great distress. Even a book, a much more adaptive regulating activity, can cause distress when discontinued.

What is the answer to these problems? I will respond in a subsequent posting!

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References

Ben-Sasson A, Carter AS, Briggs-Gowan MJ (2010). The development of sensory over-responsivity from infancy to elementary school, J Abnorm Child Psychol, DOI 10.1007/s10802-010-9435-9.

Granic I (2006). Towards a comprehensive model of antisocial development: A dynamic systems approach, Psychological Review, Vol.113, No. 1, 101-131.

Sander, L. (2008). Living Systems, Evolving Consciousness, and the Emerging Person, New York: The Analytic Press.

Vosko AM, Colwell CS, Avidan AY (2010). Jet lag syndrome: circadian organization, pathophysiology, and management strategies, Nature and Science of Sleep, https://www.dovepress.com/jet-lag-syndrome-circadian-organization-pathophysiology-and-management-peer-reviewed-article-NSS.J

Growing Flexibility in Your Child

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Recently, a mother asked me how she could help her son become less rigid in his play so that he would be more successful in his play with peers. As I sat down to respond to her question in email, I began to think about what an important question this was, and I felt inspired to write a blog posting about it.

I think of “rigidity” in terms of being the opposite of flexibility. In that sense, being rigid about something is something we all do when we are stressed, when we can’t manage flexibility. Kids develop more and more competency in dealing with the unpredictability and variability life brings them – more competency in being flexible – as they grow, and the more competent in this regard they become, the less scaffolding they need from their caregivers. Some kids need more support than others, but all need help from their caregivers in learning to be flexible. By caregivers, I mean parents, babysitters, and teachers.

One of the ways caregivers help children in this developmental process is to imagine what is going on inside the child’s mind and body. (I use the word “imagine” for two reasons. One is that you can’t really ever “know” what is going on inside another person. The other reason I will describe in a moment.)

What is the child’s intention? Where is the child in relation to accomplishing his goal? In other words, what is his state? Is he relaxed and focused? Is he comfortable but a little scattered? Is he fatigued and unfocused? Getting better and better at imagining about your child’s “state” and intention will help you attune to his needs and be able to support him. It also keeps you focused on his agency. I think of agency as perhaps the single most important factor (after basic needs, of course) in helping children (or adults) grow – protecting it, supporting its development.

As caregivers get better and better at imagining what is going on with their child, they can then help the child take a small step in the direction the child was already heading (according to the child’s intention). This idea derives from the work of Lev Vygotsky, a Russian learning theorist at the turn of the last century, who among other things described the “zone of proximal development” – the best way to help a child learn (Vygotsky, 1967, 1978).

For example, suppose the child says in a dreamy way, as if he is musing about some plan, “On the way to school let’s stop at I-Party and get a pirate costume so that I can wear it when we play pirate ship on the playground.” The mother realizes that (1) I-Party isn’t open at 8:30 in the morning, even if she were willing to darken the doorway of that store that kids love so much; (2) They barely get to school on time anyway, given the demands of their everyday life; (3) the child hasn’t even gotten out of his pajamas yet, let alone eaten his breakfast, so doing this strange and strenuous errand is not at the top of her mind!

According to what I am recommending, first, the mother would check out his state. He has just gotten up and is in a physiological as well as psychological transition state. That means he isn’t going to manage flexibility very well. But as the mother observes him, she notices that he seems rather comfortable. He isn’t whining. He is speaking thoughtfully, and his little body is relaxed, his face smooth. She would then imagine his intention. Clearly, that is to be a pirate, probably the captain of a pirate ship. In other words, he is going to be commanding, swash buckling, and an essential member of a tight group, his pirate mates. “Hmm,” she thinks. “This fantasy has potential!”

According to Vygotsky (I am imagining this, here) the mother would say something like, “Wow. A pirate costume. That would be so great to wear when you play pirate ship! Let’s start getting dressed and think about what kind of pirate costume you would like! Would you have a hat?” What she is doing in this imaginary scenario is (1) recognizing the child’s physiological and psychological state; (2) recognizing the child’s intention; and (3) on that basis negotiating a shared agenda with him, in this case the shared agenda being getting dressed and off to school while planning a wonderful playtime during playground time. This is building competency for flexibility.

The other reason for stressing “imagining” is that the capacity for imagining, sometimes called “reflective function” is a core competency in development. Being able to imagine means being able to control your impulses (your body) and consider alternatives. If you can’t “imagine” those alternatives, you don’t have much flexibility and you tend to insist on one demand (“I need it!”). That is because you perceive the world in black and white terms and can’t see the whole world of gray in between. Parents and teachers help the child learn about that world of gray. That grows flexibility.

Currently, many child developmental researchers think that the development of flexibility and “reflective function”, so necessary in adult life, begins with the capacity of the caregiver to respond in a contingent way to the infant’s initiatives, and is developed further in the play of caregiver and child, that becomes imaginative play (pirate ships) of the child (Fonagy et al, 2005). Then, if the child can manage adequate flexibility, he can engage in imaginative play with peers at a level of greater complexity and continue to grow.

One of the problems I have noted in this otherwise excellent theory is that it is rather one-sided and focuses on what the caregiver does better or worse while neglecting the contribution of the child. As we know, some children are constitutionally better prepared to be flexible than others. Some children have early life experiences, such as medical illnesses or disruptions in their caregiving relationships that challenge them in this process. Child development is always a two-way street.

If when the mother takes these three steps with her child and in step one notices that he is slouched, his face is puckered in a frown, and his voice is whiny, she is not going to be able to negotiate the same shared agenda with him. She will have to spend more time helping him regulate his state as first priority. On this morning, she might bring him a piece of toast to eat while he is getting dressed (if that is not too out of the family rules and rituals); she might take the process of helping him through the transitions from sleep to wake, from home to school, at a slower pace from the outset; and she will ratchet down her expectations and her demands for compliance, realizing that he is struggling to just feel OK. If he says something about wanting to get a pirate costume in this state, the mother might start the same way, acknowledging the great idea of a pirate costume, but she would leave more time for getting dressed (not easy, I know!), talk him through it more (“Let’s put that foot in a sock and then think about the pirate hat!”), and make fewer demands.

As always, I appreciate the inspiration I get from the parents and children I get to know. They help me continue to grow in my ideas, and also in my flexibility!

Fonagy, P., Gyorgy, G., Jurist, E., & Target, M. (2004). Affect Regulation, Mentalization, and the Development of the Self, London: Karnac Books.

Vygotsky, L.S. (1967). Play and its role in the mental development of the child, Soviet Psychology, 5, 6-18.

Vygotsky, L.S. (1978). Mind in Society, edited by M. Cole, V. John-Steiner, S. Scribner, and E. Souberman, Cambridge, MA: Cambridge University Press.

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Romanian Orphanage Study: Dr. Charley Zeanah at UMB IPMH

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Charley Zeanah presented to the group on September 21 and 22. He has been involved in Romania for 14 years. The Romania initiative traces its beginning to a movement started by the 1909 White House Conference on Children that declared its opposition to the institutionalization of dependent and neglected children. Now institutionalization of children whose families cannot take care of them is rare in the U.S., but not in other parts of the world. Romania is a unique story. The research group was invited to study there in the context of a policy debate about what to do with all the children institutionalized by Ceausescu’s government. Under Ceausescu, the official position was that the State could do a better job in raising children than many mothers could, so mothers who were struggling with poverty or other adversities were encouraged to give up their children in the maternity hospital. After several months in the maternity hospital, if the child had no obvious problems, he was transferred to a nursery, where he stayed until 36 months. At that point, if an exam determined him to be normal, the child was sent to a children’s home.

Although there was wide variability in children’s homes, there were some important common features, including many factors working against the establishment of individualized attachment relationships with the caregivers. The children were fed around the table with little or no talking, there was a lot of “free play time” with little support from the caregivers, and aggressive behavior and expressions of distress were often not attended to. Films of this “free play time” revealed painful images of children rocking and spinning.

The study created a model foster home project in which social workers were trained to work closely with the foster families to facilitate attachment and support the foster parents. Interestingly, one of the main effects of this intervention was an increase in IQ of the children in foster families. Also, these children showed greater expression of positive emotion than the institutionalized children within a few months. When assessment was repeated after 42 months in foster families, a community control group had the best attachment to their caregivers, the foster group had medium results, and the institutionalized group had the worst outcome. The children in this last group included a high percentage of withdrawn, inhibited kids with Reactive Attachment Disorder. It is interesting to note that the characteristic “indiscriminate” attachment behavior of RAD persisted even after the group in foster care had formed attachments to their foster families.

Later, when psychopathology was assessed at 54 months, 55% of the children living in institutions had diagnosable psychiatric disorders in contrast with 22% of children in the (control) community group. Both foster care and institutionalized groups had higher levels of emotional disorders (such as anxiety and depression) and behavioral disorders (such as ADHD, Oppositional Defiant Disorder, and Conduct Disorder) than the community group. The improved cognitive outcomes in the foster care children were most significant for children placed in foster care before 24 months. Similar sensitive periods were also found for the development of language, attachment, and indiscriminate behavior. An important finding was that secure attachment at 42 months predicted psychopathological outcome at 54 months. Interestingly, there was a big gender difference, with most of the securely attached children at 42 months being girls and most of the children with psychiatric symptoms at 54 months being boys.

In conclusion, the research group found that children raised in institutions have compromised development across almost all domains, that attachment status moderates many aspects of psychopathology, and that the socio-emotional effect is more profound than the cognitive effect. When you place these children in good foster homes, you get attachment recovery and some – but not all – recovery from psychopathology. The research group strongly recommends intervening in abusive and neglectful caregiving situations as early as possible. More specifically, they propose removing children from institutions and placing them in foster homes.

I noted that this was a beautiful presentation of a study of monumental importance in child development and child psychiatry. The study demonstrates the power of the caregiving relationship to influence development. I pointed out, though, that the Romanian orphanages represent – as Dr. Zeanah explained – a rather unique and extreme caregiving situation, and that there is a problem in that is that this study of Romanian orphanages is being used by some international agencies to promote a one size fits all approach to the problem and laws such as LEPINA in El Salvador that require immediate reunification of institutionalized children with their biological families, with little or no support for their severely disadvantaged and dysfunctional families in the community.

Ed Tronick quoted the “old literature “– the first edition of Jerome Kagan’s book on child development that included accounts of children raised in institutions after WWII. These children did relatively well. How can we explain that? One possible reason is that there was a commitment to these children because of something terrible, morally bad that had been done, enhancing the caregivers’ desire to do something for them. Dr. Zeanah talked about the meaning of the children to the caregivers. In the case of Romanian orphanages, the society’s negative attitudes towards the Roma, who make up of 30% of children in orphanages, though they comprise only 6-9% of the population, may affect the caregivers’ commitment to the children.

Dr. Zeahah said that their group is interested in individual differences in response to institutionalization among the children. He noted that there may be a relationship between certain genotypes and indiscriminate behavior. They are looking at alleles that are very sensitive to experience and those that seem impervious. In that case, if you have the impervious alleles you fare well no matter what the environment and if you have the sensitive alleles you may struggle in an average expectable environment. Readers of the blog will recognize the “orchids versus dandelions” metaphor.

Apropos these last comments, I had a number of thoughts. First, I would underscore the importance of the meaning of the child to the caregivers. For example, a religious or spiritual mission to minister to children in need may allow caregivers to see the child as deserving of loving care and to recognize the unique value of each child, while also sustaining the caregiver through the frustrations and disappointments involved in their tasks. For example, the message that each child is precious to Jesus – no matter what he looks like or how much he achieves – is a powerful message indeed. It is also important to remember the orchids and dandelions story. This story emphasizes the individual characteristics of each child, including the ability – innate or acquired – to take in the good in their environment and make it part of themselves. These thoughts remind us of the complexity of development and of how important it is to continue to search for a repertoire of solutions so that we can find a unique approach to each unique challenge.

References:

Kagan, J. (1962). From Birth to Maturity, John Wiley and Sons, Inc.

Nelson, C.A., Zeanah, C.H., Fox, N.A., Marshall, P.J., Smyke, A.T., Guthrie, D. (2007). Cognitive recovery in socially deprived young children: The Bucharest early intervention project. Science, 318:1937-1940.

Nelson, C.A., Furtado, E.A., Fox, N.A., Zeanah, C.H., The deprived human brain: Developmental deficits among institutionalized Romanian children – and later improvements – strengthen the case for individualized care (2009). American Scientist, 97:222-229.

Whetten, K., J. Ostermann, R.A. Whetten, B.W. Pence, K. O’Donnell, L.C. Messer, N.M. Thielman, The Positive Outcomes for Orphans (POFO) Research Team. “A Comparison of the Wellbeing of Orphans and Abandoned Children Ages 6-12 in Institutional and Community-Based Care Settings in 5 Less Wealthy Nations.” PLoS ONE. 4(12):e8169. 2009.

Plus the new OVC researcher community at https://www.ovcwellbeing.org/