Vulnerability, Stress, and Resilience in the Early Development of a High Risk Child

Case Study Vulnerability, Stress, and Resilience in the Early Development of a High Risk Child ANN S. MASTEN, PH.D.,

AND

MARY J. O'CONNOR, PH.D.

Abstract. A young girl at risk for schizophrenia is admitted for inpatient evaluation at age 30 months with growth failure and psychosocial retardation. Her history suggests that adverse environmental experiences, particularly the traumatic loss of primary caregivers around age 15 months, resulted in symptoms consistent with the clinical picture of anaclitic depression and associated psychosocial dwarfism. Intervention in the form of hospitalization and placement by "prescribed" adoption into a favorable caregiving environment produced dramatic recovery in growth and psychological functioning. Follow-up data document sustained positive development 31/2 years later. This case illustrates the power of a developmental perspective on psychopathology for conceptualizing and planningtreatment for an individual child. J. Am. Acad. Child Adolesc. Psychiatry, 1989, 28, 2:274-278. Key Words: resilience. anaclitic depression, growth failure, risk, schizophrenia. Developmental psychopathology is rapidly emerging as a unifying theoretical and research perspective in psychiatry and psychology, with growing recognition that the phenomenology, etiology, course, prognosis, treatment, and prevention of childhood disorders will be better understood within a developmental context (Eisenberg, 1977; Cicchetti, 1984). Concomitantly, the concepts of vulnerability, risk, protective factors, stress, and coping have captured the attention of scientists and clinicians alike in their search for understanding psychopathology (Masten and Garmezy, 1985; Garmezy and Masten, 1986). In part, developmental psychopathology as a field gained its impetus from studies of children at risk due to parental disorder and perinatal or environmental hazards (Masten, in press). Risk research highlighted the need for a longitudinal perspective and broad-based measures of adaptation while pointing to the complex interplay of diathesis and environmental events unfolding in development. The following case provides a unique illustration of the power of a developmental perspective in conceptualizing and planning treatment for an individual child, and also for integrating the concepts of vulnerability, stress, and protective factors in the development and course of psychopathology. This young girl, at risk for schizophrenia, presented with growth failure and psychosocially delayed development at age 30 months. Her history suggests, first, that adverse environmental experiences, particularly the abrupt loss of primary caregivers at age 15 months, significantly contributed to the derailment of her development; and second, that a favorable

change in the environment, the prescribed treatment, led her to regain a normal developmental trajectory. Follow-up data obtained 3 years after hospital discharge to assess subsequent development suggest that a positive adaptational pattern has been sustained. Case History Referral Sara (a pseudonym) was referred for inpatient evaluation in a psychiatric hospital at the age of 30 months following an outpatient interdisciplinary team evaluation. She was in the custody of the state welfare department, living in a foster home. The initial referral for outpatient evaluation came from her pediatrician, who suspected early onset schizophrenia. The outpatient evaluation, however, suggested growth failure due to maternal deprivation. Her height, weight, and head circumference were all below the second percentile, with no medical explanation evident. Her foster mother described her as a "strange little girl" with "autistic and schizophrenic behavior" including odd postures, handwringing, head banging, and intense fearfulness around strangers. Her adoption worker also described her behavior as very unusual, with "statuesque types of gestures," screaming, and moodiness. All parties agreed that hospitalization was necessary to assess this child more thoroughly and to observe her response to a new and stimulating environment. Developmental History Very little information was available about Sara's family of origin. Her mother, who reportedly had a long history of schizophrenia, was described by welfare case workers as a petite, beautiful woman who sometimes lived on the street and made her living by prostitution, when not hospitalized. She had two other children older than Sara who had been removed from her care because of neglect. Sara's father was unknown. Her mother came into a hospital emergency room in labor. Birth records indicate that Sara was a full-term baby with

Accepted August 22, 1988. Dr. Maslen is Assistant Professor of Child Psychology and MeKnight-Land Grant Professor. University of Minnesota, Institute of Child Development. Dr. O'Connor is Associate Professor of Biomedical Psychology, Neuropsychiatric Institute. University of California, Los Angeles. This study was partially supported by a grant from the William T. Grant Foundation. Reprint requests to Dr. Masten, University of Minnesota. Institute ofChild Development. 51 E. River Rd., Minneapolis. MN 55455. 0890-8567/89/2802-0274$02.00/0© 1989 by the American Acad-

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Apgar scores of 9 and 10. Her length was 49.4 cm (50th percentile), weight was 2948 grams (25th percentile), and head circumference was 33 em (25th percentile). At I day of age, Sara was taken from the hospital by her mother against medical advice. Within a day, abandoned by her mother, she was taken into protective custody and brought to her first foster home, where she was to remain for 15 months. There were a number of other children in Sara's first foster home: a natural daughter, age 14, and three foster children, an infant Sara's age and two toddlers. The foster mother described Sara as different from the beginning: "I knew Sara wasn't like the rest of the babies." She said, "She was the type of baby who ifleft in the crib all day would have been happy." She said Sara was quite attached to her husband, who became ill sometime after Sara was one year of age. The husband died suddenly when Sara was 15 months old, precipitating a transfer of foster homes. Apparently, the foster mother contacted the welfare department when her husband died and asked that the foster children all be removed immediately. The foster mother said that she had felt a transfer would be better for Sara, who was "becoming too attached"-clinging and following her around. The first foster mother reported that Sara "seemed real smart" and had said a number of words before she left. She remembered her smiling by 6 weeks, sitting by 7 months, crawling by 7 or 8 months, and walking early, at II months. Normal motor developmental milestones were confirmed in her medical and adoption records. The day she was 15 months old, Sara was picked up by a welfare worker and transported to a new foster home, with no preparation of any kind. Sara's new foster parents were approximately 50 years old. They had four children of their own who were grown up and living out of the home. They had three adopted children at home, ages 14, II, and 6 years. There was also a foster infant, 5 months old, in the home when Sara arrived. Sara's second foster mother reported that after Sara arrived at her home she cried for a month and could not be comforted, frequently screaming. She avoided eye contact, frequently vomited her food, did not speak, and "walked so bad I thought she had an orthopedic problem." She often sat in the window, staring outside. According to the foster mother, Sara was examined by a pediatrician at 22 months and found to be "microcephalic." The pediatrician ordered skull X-rays out of concern that her skull was closing too fast. Results were negative. She also reportedly had scabies and skin problems from dried milk being left on her face. No other medical problems were

foster mother described her as very sensitive: "overreactive to negative things and underreactive to positive." She said Sara preferred solitary play and "never used toys properly," sorting and stacking toys in simple repetitive patterns. She rarely spoke spontaneously and frequently echoed what was said to her; she would stand in statue-like poses for up to 20 minutes at a time (a behavior also observed in evaluations of Sara). Her foster mother reported there had been a very gradual improvement in Sara's socially isolative behavior over the year and general improvement in her behavior, although she continued to exhibit extreme reactions to strangers entering the home.

observed at that time.

peared to be age appropriate yet she rarely spoke sponta-

Health records indicate growth failure, with a rapid deceleration in rate of growth, beginning by 15 months and continuing to admission (Fig. I). Between 15 and 30 months, Sara showed very little growth in stature, weight, or head circumference, until all three measures fell below the 2nd percentile. Developmental functioning indicated a similar deceleration in psychosocial growth and regression in some areas. Welfare records show that at age 19 months, Sara said only two words: "hi" and the name of one of the children in the home. The

neously. Sara frequently echoed one or two words. The most striking behaviors she exhibited occurred when she was separated from her foster mother and also when approached by a physician in a white coat. She either froze and remained stiff and staring like a statue for minutes at a time or walked with stiff arms and legs, evidently in great distress. Sara was admitted to a child psychiatric unit designed for young children in which a homelike milieu with consistent caregiving was a central goal. A primary nurse/caregiver was assigned to Sara. Nonetheless, daily routines included many

Outpatient Evaluation

Outpatient evaluations of Sara's physical and psychosocial development were conducted when she was 25 to 28 months of age. A complete medical evaluation indicated growth failure with no apparent organic cause. During a psychological evaluation at age 28 months, the examiner was struck by Sara's apprehension in the testing situation, even with her foster mother present. Results on the Gesell Developmental Schedules showed that Sara functioned like a 24-month old in motor skills, 22-month old in adaptive skills, 18-month old in verbal-expressive skills, and 15-month old in social-personal skills for a total developmental quotient of 74. Yet her mental age on the Merrill-Palmer Scale of Mental Tests was 27 months, yielding an IQ score of96. Her social quotient on the Vineland Social Maturity Scale was 64, equivalent to an 18-month old. In her summary, the psychologist concluded that while not mentally retarded, Sara was functionally retarded, and that she may have been severely deprived. She noted the similarity of Sara's history and behavior to cases of anaclitic depression. Hospital Admission and Course

Because of her difficulties with separation, the significance of hospitalizing this child was weighed carefully. The benefits to her life had to outweigh the cost of yet another separation. Important considerations in this decision were the benefits of hospital evaluation and treatment for failure to thrive and the possibility that the welfare department would classify her as "non-adoptable" without further reevaluation and improvement. When she was admitted, every effort was made to minimize the stress associated with treatment. On admission, this tiny, attractive child appeared to be attached to her foster mother, preferring to stay on her lap. She appeared oriented and showed a full range of affect, appropriately expressed. Her language comprehension ap-

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transitions and brief separations in order to attend the inhospital school, recreational therapy, and other activities. A special effort was made to reduce the stress of these transitions for Sara. For example, she was always escorted by hand from the ward to school and personally united with the next caregiver. Sara was very distressed the first few days, then appeared to settle in. Her foster mother did not visit, although she was encouraged to do so. Sara, however, quickly began to show attachment behavior directed toward her primary nurse, seeking proximity and allowing her to comfort her. Within a few days, Sara began to talk spontaneously in short sentences appropriate to her age. A number of her comments were directed at her peers, and were of the "give it back!" or "that's mine!" variety common to toddlers. She also became more spontaneous in her other behavior as well, and more socially responsive. Assessments were delayed until Sara appeared to be fairly comfortable in her new environment. Sara showed some

weight loss the first month, then began to gain weight. A thorough medical workup did not reveal any causes for growth failure. Fasting blood test results, which were normal, included the following: glucose, calcium, phosphorus, total and direct bilirubin, SGPT, alkaline phosphatase, free T4 index, T4 RIA, TSH, growth hormone, carotene, CBC with differential, reticulocyte count, and ESR. Bone age analysis from left hand X-rays indicated a bone age of 30 months at chronological age 30 months. Intellectual assessment showed low to normal functioning. Her self-help skills were significantly delayed, as were her language and play skills. Her performance in all of these assessments was notably variable in quality with an inconsistent range of functioning. Moreover, results were reported with the cautionary observation that her performance was rapidly improving. After 1 month of hospitalization, a case conference was held at which Sara's adoption worker was present. The multidisciplinary team evaluation converged on several conclusions: (I) Sara did not have schizophrenia or a pervasive

VULNERABILITY AND RESILIENCE IN A CHILD AT RISK

developmental disorder; (2) growth failure and developmental delays were due to stressful life events, most notably the disruption of the first attachment relationships, and to environments that did not meet Sara's needs; (3) a suitable environment would be likely to result in normalization of her growth and development; and (4) she should be adopted as soon as possible, preferably directly from the hospital. The adoption worker had not observed Sara since admission and was astounded at her progress. She requested that the most suitable family for Sara be described, and she resolved to do her best to find such a family. Prescriptionfor a New Environment The treatment team in this case was presented with a rare opportunity to match the environment to the needs of a child with a high risk history. Sara needed a very stable environment and a chance to receive consistent, responsive caregiving. She also needed mature, experienced parents who would be loving, patient, and self-confident. The team recommended a family be selected in which there were other children who were older (no infants or toddlers), a mother who would be home most of the time, and a family that planned to remain in the same place for the foreseeable future. The family would also have to accept the risk of a child with a mentally ill biological mother. After Sara had been hospitalized for 2 months, a family meeting these criteria was found. The parents were in their mid-thirties and had two sons, 8 and 12 years old, and were seeking to adopt a daughter. They had lived in the same house for many years and had no plans to move. The two parents visited Sara daily for 2 weeks prior to taking her home. The family was provided support and education by the treatment team. They learned Sara's daily routine and were educated in behavioral management techniques. Sara responded positively to them and spontaneously began to call them Mommy and Daddy before she went home to live with them. By the time she left the hospital, over the course of 3 months Sara had gained a year in most areas of psychological development. She also showed small gains in stature and weight. Her adopted mother kept in touch with the staff and called to consult them about concerns that arose during Sara's adjustment to her new home. Sara had some sleeping problems at first but appeared to adapt well to her new life. She continued to increase in spontaneity and began to enjoy friends her own age. She grew 1104 em, the first year, which put her back on a normal growth trajectory (see Fig. I). Follow-up Assessment Three and a half years after discharge, Sara's mother agreed toa follow-up assessment. This evaluation included an interview of the mother and psychological assessment of Sara in their home, behavioral questionnaires completed independently by the mother and the first grade teacher, and medical records of height and weight obtained from her pediatrician. The psychological battery included the Wechsler Preschool and Primary Scale of Intelligence, the Beery-Buktenica Test of Visual-Motor Development, Peabody Individual Achieve-

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ment Test (PlAT), Thematic Apperception Test (TAT), Sentence Completion Test, and drawings. The psychometrist who administered the tests was blind to all historical and previous test data. She described Sara as attractive, friendly, cooperative, and easy to engage. Cognitive functioning was consistently within the average range. The full scale IQ score was 100. Perceptual-motor skills were also age appropriate. Responses to the personality tests were developmentally appropriate as well, although her stories suggested a persistent theme of sadness. For example, of 10 TAT stories, six were about a little boy or girl who was sad or crying. Her first grade teacher reported grade level performance in all subjects but spelling, which was "somewhat below grade level." Sara's PlAT scores for reading and spelling were at the first grade level. On the Teacher's Report Form of the Child Behavior Checklist (Achenbach & Edelbrock, 1983), no problems were indicated by the teacher. She commented: "Sara is a welladjusted child, she's outgoing and she always has a smile on her face. I enjoy having her in my class." Her competence ratings of Sara describe her as attractive, popular with her peers, and well-behaved. In her ratings on the Child Behavior Checklist and in the interview, Sara's mother also described her as a happy, competent child. She reportedly had playmates, was getting along with her brothers, and was generally well-behaved at home. She attended a small, private school, and was performing well. Her mother reported that she did have separation problems in leaving her mother to go to school, often crying before she left. Her mother said this had decreased over the school year. Sara was also described as sensitive, crying easily, yet able to cope with new or moderately stressful experiences, such as her first visit to the dentist. Her health had been excellent, her mother reported, except for an itchy rash that appeared periodically on her face and limbs, consistent with earlier skin problems. Her mother attributed the rash to "nerves" because it seemed to her to appear at times of stress, such as the beginning of school. Sara's pediatrician rated her health as excellent, with no problems. At age 61f2, she was 115.6 em tall and weighed 19.5 kg, at about the 35th percentile in both height and weight. Sara's mother reported more recently that she continues to develop well in all areas. She did well in second grade and all traces of separation anxiety when leaving for school have disappeared. Discussion The case of Sara provides an example of both what we do and do not know about the roles of vulnerability and life stress in development. By virtue of her mother's illness, Sara may have an elevated risk for schizophrenia, 8 to 10 times greater than the population risk of about 1% (Gottesman and Shields, 1982). However, her actual vulnerability-her specific susceptibility-to this disorder is with present knowledge unknown. None of her behavior or developmental problems thus far can be specifically linked to her high risk status. However, early descriptions of Sara in infancy and her subsequent behavior under stress raise the possibility that she

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may have been more sensitive or temperamentally difficult than an average baby, who needed a good environmental fit to buffer her development (Chess and Thomas, 1984). Neither of her foster homes appears to have been a good match for her needs. Nonetheless, judging from her reaction to losing them, Sara apparently formed a strong attachment to her first foster parents. Moreover, her development in the first year appeared to be appropriate until the time of her foster father's illness. Sara probably began to "lose" her caregivers shortly before age 15 months, with the onset of her foster father's illness. His illness may have affected his parenting as well as created stress for her foster mother. Then he died and Sara was abruptly transferred to a new home, thus permanently losing both her first attachment figures. These events, followed by apparently inadequate caregiving in her second placement, appear to have had a profound affect on Sara's cognitive, social, and physical development. The timing of this series of stressors probably heightened the effect. Children appear to be more vulnerable to separations from the primary caregiver between the agesof6 months and 4 years, when specific attachment relationships are first formed and separation anxiety is most intense (Bowlby, 1980; Rutter, 1979). Separation anxiety often peaks near the age when Sara was moved. Descriptions by her first foster mother suggest she was showing symptoms of insecure attachment prior to the move (e.g., "clinging too much"), which could have been a normal developmental phase or may have reflected increased family stress due to the father's illness. Sara's behavior followingthe sudden change offoster homes is consistent with classical separation/loss behavior patterns described by Bowlby and others (Bowlby, 1973; 1980) and anaclitic depression described (in somewhat younger infants) by Spitz (1946) and Call (1987), which follow loss of the maternal figure in early development. Over a span of several months, Sara looked sad and cried for long periods of time. For a month she could not be comforted. Her eating and sleeping were disrupted. She stopped talking, socializing, and playing, and regressed in motor development. Her behavior suggests intense grief and a prolonged aftermath, congruent with what was for her a catastrophic stressor. Had she been evaluated at age 16 months, her behavior probably would have met the DSM-Ill criteria for major depression (Call, 1987). Sara's history and course are also consistent with the clinical picture of "psychosocial dwarfism" (Green et al., 1984). Ferholt et aJ. (1985), based on their observations of children with apparently psychosomatic growth failure, have suggested that a "very slow rate of linear growth can be understood as a neuroendocrine concomitant of a severe depressive disorder in a person who is still growing." Sara's growth retardation may have been secondary to depression caused by the loss of primary caregiversat a sensitive age in a potentially vulnerable child. Before admission, Sara was falling increasingly behind in psychosocial and physical development, not maintaining the rapid growth rate characteristic of this period. Intervention,

in the form of diagnostic and therapeutic hospitalization and subsequent adoption into a home well-suited to her needs, appears to have facilitated her development such that she rapidly regained a normal developmental trajectory, both in terms of physical and psychological development. The main ingredient in this intervention was the provision of a suitable caregiver, supplemented by a stable and supportive home environment. At present, Sara appears to be developing normally. However, her specific vulnerability to schizophrenia remains unknown, and her history as well as the sorrowful theme in her projective test responses raise the possibility that she may have acquired a vulnerability to depression or heightened sensitivity to loss events as a result of her experiences (Brown and Harris, 1978; Bowlby, 1980). Nonetheless, Sara's capacity to recover, given adequate environmental resources, should not be overlooked. A capacity for resilience (Masten, in press) may also have genetic and environmental roots that are enduring in their influence. References Achenbach, T. M. & Edelbrock, C. (1983), Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: Thomas M. Achenbach. Bowlby, J. ( 1973), Attachment and Loss. Volume II: Separation. New York: Basic. - - (1980), Attachment and Loss. Volume Ill: Loss. New York: Basic. Brown, G. W., & Harris, T. O. (1978), Social Origins ofDepression. New York: Free Press. Call, J. D. (1987), Psychiatric syndromes of infancy. Basic Handbook ofChild Psychiatry, 5:242-261. Chess, S. & Thomas, A. (1984), Origins and Evolution of Behavior Disorders from Infancy to Early Adult Life. New York: Brunner/ Mazel. Cicchetti, D. (1984), The emergence of developmental psychopathology. Child Dev., 55:1-7. Eisenberg, L. (1977), Development as a unifying concept in psychiatry. Br. J. Psychiatry, 131:225-237. Ferholt, J. B., Rotnem, D. L., Genel, M., Leonard, M., Carey, M. & Hunter, D. E. K. (1985), A psychodynamic study of psychosomatic dwarfism. J. Am. Acad. Child Adolesc. Psychiatry, 24:49-57. Garmezy N. & Masten, A. S. (1986), Stress, competence, and resilience: common frontiers for therapist and psychopathologist. Behavior Therapy, 17:500-521. Gottesman, I. I. & Shields, J. (1982), Schizophrenia: The Epigenetic Puzzle. Cambridge: Cambridge University Press. Green, W. H., Campbell, M. & David, R. (1984), Psychosocial dwarfism. J. Am. Acad. Child Adolesc. Psychiatry, 23:39-48. Hamill, P. V. V., Drizd, T. A., Johnson, C. L., Reed, R. B., Roche, A. F. & Moore, W. M. (1979), Physical growth: National Center for Health Statistics percentiles. Am. J. Clin. Nutr., 32:607-629. Masten, A. S. (in press), Resilience in development: Implications of the study of successful adaptation for developmental psychopathology. In: Rochester Symposium on Developmental Psychopathology(Vol. I), ed. D. Cicchetti. Hillsdale, NJ: Lawrence Erlbaum. - - & Garmezy, N. (1985), Risk, vulnerability, and protective factors in developmental psychopathology. In: Advances in Clinical Child Psychology, Vol. 8, ed. B. B. Lahey & A. E. Kazdin. New York: Plenum, pp. 1-52. Rutter, M. (1979), Maternal deprivation, 1972-1978. Child Dev., 50:203-305. Spitz, R. A. (1946), Anaclitic depression: an inquiry into the genesis of psychiatric conditions. Psychoanal. Study Child, 2:313-342.