Infant/Child Response to Grief

When a child is adopted, I believe many (poorly prepared) APs will (wrongly) assume the variety of unwanted behaviors exhibited by the adopted child will only indicate and prove just how neglected that child was by previous care-takers.  I'm not sure how many APS recognize even good change - like change to a new bed or room, or country - is a very real stress, and that stress can be seen and experienced as tremendous loss and trauma for a very young child.  In other words, not all signs of delayed development are the direct result of parental neglect and abuse. 

Below outlines signs and behaviors related to stress, trauma, grief, and loss, as it may be experienced by an adoptee whose biggest loss involves all that was known and familiar, like sights, sounds, tastes and smells.

Signs of a Grieving Child

Infants/Pre-verbal Toddlers:

  • Decrease in activity level
    Infants who were attempting to rollover, crawl, and walk prior to the traumatic event may stop attempting movement. This is typically temporary and after some time will begin those attempts for movement again. However, it is important to offer infants/toddlers the opportunity for those attempts at movement. Also, be sure to continue to play and encourage, but not coerce, those attempts at movement.
  • Decrease in appetite
    Due to change in routine and caregiver, infants are often unsure of their environment and while they are becoming familiar with their new routine they often are irritable and will not eat as much. There may also be a weight loss. If the child’s decrease in feedings and weight loss continues for several weeks, it is important to have a check-up with the child’s family doctor or pediatrician. However, typically the infant/toddler will adjust and begin eating the same amounts as before the trauma.
  • Increase in irritability and/or change in personality
    Caregivers often report that children in this age range typically experience irritability, primarily because of a change in their daily routine. In general, when there is a change in any child’s routine, there will be some amount of stress, which will cause irritability and/or a change in personality. However, once the child becomes adjusted to his/her new schedule they typically return to the infant you knew prior to the trauma.
  • Sleeplessness
    Once again a change in routine will also affect sleeping patterns. The infant must again learn to trust their caregiver. So, be sure to provide him/her the individual attention s/he needs. This may include sleeping in the room or being present while they fall asleep. We do NOT recommend that caregivers allow infants and toddlers to sleep in the adult bed with caregivers. There are several safety concerns and an increased risk for accidents coinciding with infants sleeping beside adults. The sleeplessness should deplete over time as well.

Toddlers, Preschool, and School Age

  • Decrease or increase in appetite
    Eating “comfort foods” is an appropriate response to any type of stress in adults and children. Many children challenge their caregivers by demanding to eat the same types of foods for every meal. This is a child’s attempt to restore a sense of power and safety after experiencing a powerless situation. It is acceptable to allow the child to eat “comfort foods” during this time. Caregivers may choose to compromise with children, in that children can eat their “comfort foods’ as long as they also eat healthy foods. This will ensure that the child is receiving the nutrients they need for extra energy. It is typically a short term coping mechanism for every human and will dissipate after a couple weeks
  • Severe increase in activity level
    You may observe in children, typically males, an increased activity or hyperactivity. Many traumatized or grieving children are misdiagnosed with Attention Deficit/Hyperactivity Disorder (ADHD). However, for traumatized children this is once again an attempt to gain control over their already powerless situation. Children also cope with fears, anger, and intense emotions in the physical sense versus verbalizing their fears, anger, and emotions. This is a healthy, normal response to a traumatic event.
  • Severe decrease in social activities
    You may observe that children who were once very active in school or social activities becoming withdrawn and quiet. These children are choosing to cope by processing this experience individually before processing with family and friends. It is wise to let this child process alone, without pressuring him/her to “talk about” the death.
  • Hyper vigilance
    Children will often participate in attention seeking behaviors that may or may not be harmful to self or others. As an educator, you have to be sure the safety of other students and staff is kept at all times. Therefore, if a suspension is needed, view it as a “teachable moment”. During your parent-teacher/administrator meeting have the social worker or counselor educate the child, parents, teacher, and administrators about typical grief responses to death visible in children. Adults surrounding this child may be unaware that this behavior is related to any type of loss. As a parent, you must attempt to communicate consequences to behaviors. If your child’s behavior continues seek professional help in efforts to restore that child’s sense of safety and power.
  • Dreams and nightmares
    Children directly exposed to a traumatic event, such as a shooting, domestic violence, car fatality, or witnessing a classmate’s death, are likely to have intrusive nightmares. However, children who experience a death of loved one may also have vivid dreams about the loved one. Do NOT assume that their dream was scary. Simply ask your child to describe the dream or nightmare. Be sure to process those dreams and nightmares with your child. If they refuse to talk about the dream, simply offer your support and encourage them to talk to peers if they feel comfortable. Always, ask children what ways you can help them to feel safe. This might include a spray bottle of “magic disappearing potion” or a flashlight. To reduce dreams it is important to provide an environment for your child that is peaceful, cozy, and safe. You can do this by playing calming music before bedtime, reading calming books before bedtime, and allowing children to sleep where they feel safe, which may include the closet, couch, and floor.
  • Sleeplessness
    Children are simply fearful and afraid of what might happen next, causing intrusive nightmares leading to lack of sleep. These children may also begin sleeping in odd places, such as on your bedroom floor, in the closet, under the bed, or on the couch. These children are attempting to restore a sense of safety and control over their fears. Children may show this behavior for several months. As adults and caregivers it is essential that we show our support by making that a comfortable place for that child. This may include allowing them to sleep in their favorite sleeping bag or bedroom comforter, having a dog or cat sleep beside them, or having a nearby light on throughout the night. Once the child observes that the adults around him/her believe in their “safety plan” the child has a restored sense of safety and will most likely return to their own beds
  • Break down in communication (specifically in adolescents)
    Parents may notice a decrease in communication with their adolescent. Teenagers, specifically, will process their grief with people outside the traumatic event to protect those that they care about. We often refer to this as the “protection game.” Parents also want to protect their child from intense emotions and trauma-inducing incidents and therefore do not speak of the incident. Children do not want upset their parents either and protect them by not discussing the incident. However, both children and parents still grieve, but by "protecting" each other they are forced to process their grief by themselves. It is okay for parents to share their own response to grief with their teenager and vice versa. However, some teens will still choose to process their emotions with peers or other adults, which is also healthy. Parents can still share their grief, but should not without a discussion. Teens who do not share their emotions with their parents are most likely processing their grief with peers and teachers. This is typical and healthy of adolescents.

Points to Remember:

  • In all aged children it is essential that caregivers attempt to keep a child’s daily schedule as close to their own routine as possible. Children become easily agitated when they do not know what to expect next. If there is a change in their routine, let them know before it happens if at all possible. Communicating with children helps to restore their trust in you as a caregiver.
  • Children grieve intermittently. Children’s grief is similar to a ping-pong ball; you never know which direction they are headed. Therefore, follow children where they lead you. Allow them to tell their story, on their terms, magically or seriously, let them lead!

Failure to recognize another source

Just for my own amusement, I searched the term "Failure to Thrive", so I could compare it's symptoms/causes to this newly defined "Institutional Autism".  Note what risk-factor increases failure to thrive [HINT:  Think orphanages stock-piling babies for adoption]

What Is Failure to Thrive?

Although it's been recognized for more than a century, failure to thrive lacks a precise definition, in part because it describes a condition rather than a specific disease. Children who fail to thrive don't receive or are unable to take in, retain, or utilize the calories needed to gain weight and grow as expected.

Most diagnoses of failure to thrive are made in infants and toddlers - in the first few years of life - a crucial period of physical and mental development. After birth, a child's brain grows as much in the first year as it will grow during the rest of the child's life. Poor nutrition during this period can have permanent negative effects on a child's mental development.

Whereas the average term baby doubles his or her birth weight by 4 months and triples it at 1 year, children with failure to thrive often don't meet those milestones. Sometimes, a child who starts out "plump" and who shows signs of growing well can begin to fall off in weight gain. After a while, linear (height) growth may slow as well.

If the condition progresses, the undernourished child may:

  • become disinterested in his or her surroundings
  • avoid eye contact
  • become irritable
  • not reach developmental milestones like sitting up, walking, and talking at the usual age

What Causes It?

Failure to thrive can result from a wide variety of underlying causes. Some children fail to thrive because of:

  • social factors. In some cases, doctors may not identify a medical problem, but may find that the parents are actually causing the failure to thrive. For example, some parents inappropriately restrict the amount of calories they give their infants. They may fear their child will get fat or put him or her on a limited diet similar to one they follow. Or, they may simply not feed the child enough either because of a lack of interest or because there are too many distractions in the household, which contributes to the neglect of the child. Living in poverty can also lead to an inability to provide a child with the necessary nutritional requirements.
  • conditions involving the gastrointestinal system like gastroesophageal reflux, chronic diarrhea, cystic fibrosis, chronic liver disease, and celiac disease. With reflux, the esophagus may become so irritated that the child refuses to eat because it hurts. Persistent diarrhea can interfere with the body's ability to hold on to the nutrients and calories from food that's eaten.

    Cystic fibrosis, chronic liver disease, and celiac disease are conditions that limit the body's ability to absorb nutrients. These are known as malabsorptive disorders - the infant may eat a lot, but his or her body doesn't absorb and retain enough of that food. Celiac disease results from a sensitivity to a dietary protein found in wheat and certain other grains. The immune system's abnormal response to this protein causes damage to the lining of the intestine, interfering with its ability to absorb nutrients.

  • a chronic illness or medical disorder. If a child has trouble eating - because of prematurity or a cleft lip or palate, for example - he or she may not take in enough calories to support normal growth. Other conditions that can lead to failure to thrive would include cardiac, endocrinologic, and respiratory disorders. These disorders can increase the child's caloric needs so that it becomes difficult to keep up with them.
  • an intolerance of milk protein. This condition can initially lead to difficulty with absorbing nutrients until it's recognized. It can also put an entire class of food out of reach, restricting the child's diet and occasionally leading to failure to thrive.
  • infections (parasites, urinary tract infections, tuberculosis, etc.), which place great energy demands on the body and force it to use nutrients rapidly (and the appetite may be impaired as well), sometimes bringing about short- or long-term failure to thrive.
  • metabolic disorders, which can also limit a child's capacity to make the most of calories consumed. Metabolic disorders might make it difficult for the body to break down, process, or derive energy from food, or they can cause a buildup of toxins during the breakdown process, which can make the child feed poorly or vomit.

In some cases, doctors are unable to pinpoint a specific cause.

Although doctors in the past tended to categorize cases of failure to thrive as either organic (caused by an underlying medical disorder) or inorganic (caused by caregivers' or parents' actions), they're less likely to make such sharp distinctions today. That's because medical and behavioral causes often appear together.

For instance, if a baby has severe reflux and is reluctant to eat, feeding times can be stressful for a caregiver. He or she may become tense and frustrated, and this may make it difficult for the caregiver to sustain attempts to feed the child adequate amounts of food.

How Is It Diagnosed?

Many normal babies go through brief periods when their weight gain plateaus or they even lose a little weight. However, if a baby doesn't gain weight for 3 consecutive months during the first year of life, doctors usually become concerned.

Doctors diagnose failure to thrive by using standard growth charts to plot the child's weight, length, and head circumference, which are measured at each well-baby exam. Children who fall below a certain weight range for their age or who are failing to gain weight at the expected rate will likely be evaluated further to determine if there's a problem.

Along with obtaining a thorough medical and feeding history and performing a detailed physical examination, the doctor may order a complete blood count, urinalysis, and various blood chemical and electrolyte tests that can be helpful in the search for underlying medical problems. If the doctor suspects a particular disease or disorder as a possible cause, he or she may perform additional specific tests to identify that condition.

To determine whether the child is receiving enough food, the child's doctor (sometimes with the help of a dietitian) will do a calorie count after asking the parents what the child eats every day. And talking to the parents can help a doctor identify any problems at home, such as neglect, poverty, household stress, or feeding difficulties.

How Is It Treated?

Children with failure to thrive need the help of their parents and a doctor. Sometimes, an entire medical team will work on the child's case.

In addition to the child's primary doctor, the team might include a nutritionist to evaluate the child's dietary needs and an occupational or speech therapist to help the caregiver and child develop successful feeding behaviors and address any sucking or swallowing problems the child might have. Occupational and speech therapists are often helpful because of their expertise in the muscular control that's involved in eating.

Because treatment of failure to thrive involves treating any disease or disorder causing the problem, specialists such as a cardiologist, neurologist, or gastroenterologist may also be part of the care team.

Particularly in cases of failure to thrive that are thought to be caused by caregivers' or parents' actions, a social worker and a psychologist or other mental health professional may help address problems in the child's home environment and provide any needed support.

Often, in cases of poor nutrition, the treatment can be carried out at home, with frequent follow-up visits to the doctor's office or clinic. The doctor will recommend high-calorie foods and place an infant on a high-calorie formula.

More severe cases may call for tube feedings in which a tube is put in that runs from the nose into the stomach. Liquid nutrition is provided at a steady rate through the tube. Once the tube is put in place, the child is usually fed at night, so as not to interfere with his or her activities or limit the child's desire to eat during the day. (About half of a child's caloric needs can be delivered at night through a continuous drip.) Once the child is more adequately nourished, he or she will feel better and will probably start to eat more on his or her own. At that point, the tube can be removed.

A child with extreme failure to thrive may need to be hospitalized so that he or she can be fed and monitored continuously. During this time, any possible underlying causes of the condition can be evaluated and treated appropriately. This also gives the treatment team the opportunity to observe firsthand the caregiver's feeding technique and the interaction between caregiver and child during feedings and at other times.

How long treatment lasts varies significantly from case to case. Weight gain takes time, so several months may pass before a child is back in the normal range for his or her age. Children who require hospitalization may stay for 10 to 14 days or more to establish satisfactory weight gain, but it can be many months until the symptoms of severe malnutrition are no longer present. Failure to thrive caused by a chronic illness or disorder may have to be monitored periodically and treated for even longer, perhaps for a lifetime.

Does My Child Have Failure to Thrive?

If you're worried that your child is failing to thrive, remember that there are many reasons why he or she might be slower to gain weight other than failure to thrive. For instance, breastfed babies and bottle-fed babies often gain weight at different rates in the early newborn period.

Genetics also play a big role in weight gain, so if you and your spouse are slim, your baby may not put on pounds quickly. However, infants should still gain weight steadily and it can be difficult to monitor this from home. So, it's important to see your child's doctor on a regular basis.

As a guideline, babies usually eat eight to 12 times in a 24-hour period (a couple of ounces [60 milliliters] every few hours) in the first weeks after birth. By the time they're 2 to 3 months old, the number of feedings has dropped to six to eight, but the amount they eat each time has increased. At 4 months, about 30 ounces (890 milliliters) a day provides sufficient nutrition for most infants.

Your child's doctor will have plenty of opportunities to identify a problem at regular well-baby checkups. You can also periodically check your baby's weight at home, if you feel you need the reassurance.

When Should I Call My Child's Doctor?

If you notice a drop in weight gain or your baby doesn't seem to have a normal appetite, get in touch with your child's doctor. Any major change in eating pattern also warrants a call to the doctor. Toddlers and other kids may have days and sometimes weeks when they show little interest in eating, but that shouldn't happen in infants.

If you have trouble feeding your baby, your child's doctor can offer some advice. For any reason, when a child doesn't readily eat, parents tend to become frustrated and feel they aren't taking care of their child well. That can magnify the problem and increase the stress for both you and your baby. Instead, get help for both of you by consulting your child's doctor.

Updated and reviewed by: Barbara P. Homeier, MD
Date reviewed: April 2005
Originally reviewed by: Steven Dowshen, MD



Editing update 2012:  Note the various ways maternal deprivation affects the neonate, as it would apply to infant adoption (when the infant and mother are forced to separate)

In simple terms, these findings help prove Nancy Verrier's "Primal Wound Theory" is more than just a description given to the psychological wounds caused by maternal separation.  Maternal separation can, in fact, cause injury to the newborn's gut --making normal growth and devlopment more complex and difficult.  How often is THIS discussed with mothers encouraged to relinquish their newborns so an adoption-plan can be completed? 

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