Hey guys, thanks so much for joining us today on Behind the Curtain. I'm your host, Rebecca Harvin, and this is where we have honest conversations about foster care and adoption. My guest on the show today is Dr. Putnam. He is a professor of clinical psychiatry at the University of North Carolina School of Medicine and an emeritus professor of pediatrics and child psychiatry at Children's Hospital Medical Center, University of Cincinnati College of Medicine. Following completion of his residency in adult psychiatry at Yale University in 1979, Dr. Putnam joined the National Institute of Mental Health Intramural Research Program in Bethesda, Maryland, where he studied patients with multiple personality disassociative identity disorder and noticed that large numbers of his adult patients had been abused as children. This led him to complete a fellowship in child and adolescent psychiatry and to focus his research on the psychological, biological, and social effects of child abuse. He co-founded the Longitudinal Female Growth and Development Study in 1987, which is still ongoing assess the consequences of childhood sexual abuse on female development. He is a leading authority on disassociative disorders. Dr. Putnam is the author of Diagnosis and Treatment of Multiple Personality Disorder, a perennial classic in the field of disassociative disorder diagnosis and treatment. He is currently involved in the development and dissemination of large-scale treatment and prevention programs for child trauma, pathological disassociation, postpartum depression, and family violence. This is, I believe, a necessary conversation to have for our children who have come to us through foster care or adoption. We will do our best to be as sensitive as possible around these topics, but this might not be a podcast that you want to listen to with children in your car. So with that, welcome to the show, Dr. Putnam. Thanks so much for being here.
SPEAKER_02Thank you very much for having me. It's I appreciate the opportunity to speak to foster parents and adoptive parents. I've had opportunities to work with them for many years and been involved in some uh programs and research with them. And um I just I I really feel like this is one of the hardest jobs on earth, and and anything we can do to make it better is important.
SPEAKER_01Yeah, I would agree. Absolutely. It has definitely been one of the hardest things I have ever done in my life. And I'm constantly looking for ways to better understand um how we can help children and how we can provide better care. Um and all of our kids have come to us. I mean, the very definition of foster care is that they have to have experienced severe abuse, abandonment, or neglect, right? So your field of work um lines up exactly with how this affects them moving forward.
Can we, real quick, can you define for us um the big words that I use, like longitudinal study? Um, what does that mean in your field?
SPEAKER_02Well, let me just talk a little bit about the study, and I think the meaning of those words will become clearer. Um I really, as a result of my first working with adults and discovering that they had these very common histories of child maltreatment, I began to to work and look really first just to look for children who had a lot of behavioral problems. And so I wasn't looking for maltreatment per se. I was looking for children who were having a lot of behavioral problems, particularly ones that might be having behavioral problems related to the dissociative disorder diagnosis, the sort of multiple personality disorder diagnosis. And so I began seeing these children in the sort of early to mid-80s, and really came to the realization that the common factor across all of them was child maltreatment and particularly uh child sexual abuse. And this was a time when really foster parents and and even the foster agencies really knew very little about what happened to these children with regard to things like maltreatment. Um, most of the time the history consisted of we think the child was abused, but nobody knows exactly what happened, sort of thing. So I began to see these children in clinic, usually with the in the context with the foster care mother or the adoptive mother or other caretakers in that case, and uh followed many of them for uh a number of visits and felt that what we really had to do was look at these children over a long length of time. So that's the longitudinal part of the study. That is, we started out with a group of about uh actually 90 plus sexually abused girls who were ages six to 15 when they were enrolled in the study, along with a non-abusing caretaker, and an equal number of comparison girls who were matched on socio and economic demographics and also uh race and age, and um we've and and also whether they came from one or two parent uh caretaker families. And we started following them forward in time, and that's the longitudinal part of it, and we're still working with them, and we're now out close to 40 years, really. I say 35 years, because that's some of the people who joined the study last, but most of the group is now we've been following for 40 years. We've seen them uh about eight times uh at this time. Some of them we've seen, haven't seen every time we've had an evaluation. And we've been following a lot of different things. We've been following obviously emotional development and psychological features, also cognitive features and an intelligence, but also many biological features, uh, particularly related to stress and trauma uh kinds of things. And we um uh have been looking at outcomes in terms of uh both their own parenting. We've looked at their children, and of course, we had their mothers in the first three or four visits when they came to see us. So we actually have data on three generations the girls themselves, the mothers of the girls, uh the biological mothers or foster mothers, and we have uh their children. And so we we have the opportunity to look across three generations uh and and see sort of how these impacts of early trauma are embedded uh behaviorally and also biologically. Uh so that study is still going on. In fact, I just got a paper today to review that we are writing about um the relationship of some of the biological factors to uh in domestic violence. So it's it's um it's a it's a complicated study. There's better than 50 scientific papers published about it. I tried to summarize it all in a book called Old Before Their Time, because that's one of the major findings from the study is that we see an accelerated aging, accelerated biological aging. So biologically, they are older than their uh chronological or birth age. Okay. Is it a lot too much?
SPEAKER_01No, it's not a lot at all. It is um that makes sense to me, right? When we hear uh how traumatic events can impact the
the body, can affect the body. It makes sense to me that it ages before its time, old before their time. That title makes sense. What has been the most surprising finding for you? Well, actually biological age?
SPEAKER_02Yes, yes. The fact that we we started out back in the 80s, and a lot of the technology was not available to us at that time. Um, but we started looking at things like uh passage through puberty, because that's a period when girls uh have a lot of mental health problems. Or the the sort of frequency of mental health problems in uh young girls triples as they're passing through puberty and and just in general. Um so we were there that was the age six to fifteen, and then we followed that cross-section forward uh in time, and we saw that, for example, they had accelerated puberty. They went into puberty earlier and they went through puberty faster, and so that they were um physically mature um at earlier ages than their matched comparison girls. And uh we know, for example, that that's a very difficult thing for a girl to be uh more mature than their peers. Uh she gets become uh often targeted by predatory males, for example. Uh, we also followed development of cognition, we followed emotional development, we followed their social networks, uh, we followed their school performances and and occupational attainments. Um and I would say when we finished the bottom line scene, they were ahead of the curve on everything in the sense that they were developing earlier, but they also peaked much sooner, and the drop-offs were much more precipitous. So if you look at something like cognition, um they their verbal IQs peaked earlier, but um, and they also started down. We all we all have this curve, you know, it's undeniable that we all sort of have an intellectual peak and then we start losing it, and and this happens to them earlier. Um, we have other data, again, relating uh maltreatment, childhood maltreatment to earlier um medical problems uh and that sort of thing. And we're certainly seeing the same thing with our sample.
SPEAKER_01And is this specifically related to sexual abuse, or have you seen this with maltreatment across the board?
SPEAKER_02Well, yeah, we see it with maltreatment across the board, but it is maximized with sexual abuse, uh, particularly um abuse in context of the family. Um and younger abuse, longer durations, more force and coercion. Those are all factors that are associated with uh worse outcomes. Um, but you can see this with other kinds of trauma, and the traumas are in fact really synergistic. If you have two or three or four traumas, they gang up on you, and you get a greater effect than the sum of the parts uh sort of phenomena. We've actually been able to actually do a little bit of dissecting of that and see what the contribution of different types of trauma are. And uh sexual abuse is the worst, and then physical abuse, exposure to domestic violence are are three of the worst things, and then combination, they're they're very potent.
SPEAKER_01It's interesting that you talked about puberty um coming showing up earlier, coming on stronger, them getting through it faster. We see on our end from a from a very not clinical um with not without having a clinical background, that children in our homes, uh in our community of foster and adoptive homes, like when puberty hits, puberty combined with with trauma is explosive in homes. It is explosive in how behaviors show up, the the way that they interact with peers and and authority figures, relationship. It is it's like buckle up. Puberty is hard anyways, but you you see this in foster care, and it's like this is this is wild.
SPEAKER_02Yes, yes, no, this is exactly right. This this is a moment, really a period of time, and this is when they get into a lot of trouble.
SPEAKER_01And then once that starts happening, is there a chain of events that starts typically? Like once they start getting into trouble, is it hard to turn that around? Have you seen that clinically? Or is it like um it's still one decision at a time?
SPEAKER_02Well, I think this is a a really important question is how do we break this cycle? Yes, yeah, uh, and how do how do we intervene here? Yeah, yes, it's clearly once things start to happen,
they start to happen in a lot of domains, you know, and and um that's and they are compounding and converging and they they build on each other with kind of retraumatization often for these children. So, so it becomes very important to, I think, recognize that these children are set, you know, early on that they're set set up for these things to happen and to be on top of them and to be careful in terms of monitoring them uh uh uh when they start when they start entering puberty and really even a bit before puberty. Um are there things we could do? I I think there are. Um it's uh we can talk about that in a little bit if you want. Um I don't there are no magic. There's nothing magic. But but I have been involved in developing uh interventions for foster parents. Um, and then we can talk about that.
SPEAKER_01Yeah, I'm sure that you have seen um I'm sure that you have seen something work over time, like hey, when this is done consistently over time, we have better outcomes. Like oh yeah, yeah. It's still hard inside of their bodies, right? But but we in healthy relationships and without any further abuse happening, we have we have a shot here. Yes, safety and security, safety and security. Safety and security, yeah. The um when you were talking about in the 80s and they would come in, and child protective services at the time would say, like, well, we think that something is happening, but we don't really have the evidence to say that it is. And now we have all kinds of um medical examining that can be done to say yes, there was or or there was not. But oftentimes what what I've seen is that a child comes into care, and maybe there's a hint of this in the background, but um, they don't feel safe enough yet to say that anything has happened to them, right? And then over a couple months in a foster home, they start feeling more safe and they start disclosing information to oftentimes their foster mom. And I think it is really difficult, or I have seen it be difficult for foster moms to get somebody to believe them when they're talking about sexual abuse in the kids in their home and it being linked to certain behaviors in their home because these aren't public behaviors, right? This is these aren't public conversations. And so how would you um encourage anybody who knows of sexual abuse that has happened when they're disclosing it to be heard?
SPEAKER_02Whoa, that's that's a lot. Um let's back up a little bit, okay? Um you know, I mean, I first of all I think it's it's it's very helpful for the foster care parents to know
what's happened to the child. And often you don't need to go to the child per se. I mean, you need to go to the foster agency and also to child protection services, where you can. And if states vary and counties vary, there's enormous variability here. When um I've dealt with about 20 or 30 different counties and child protection services, and I just see enormous variability across them. So it's really hard to make uh clear-cut generalizations, but um and get as much information as you you can from them. And then there are really the behaviors are the things to be watching. Uming what happened to the child helps understand some of the behaviors, but that's not going to fix the problem, if you understand what I mean. Um, I think what's important is that the foster parents believe them. Um getting getting heard and believed. I mean, look how difficult it is for some group like the Epstein survivors to be heard and to be believed. And they have the advantage of, you know, a group of them who have had the same experience, and they're adults, and and um it's it's very it's very difficult. Um, I mean, our society is terrible this way. Um I uh one of the most important things we do is talk about it and and really bring it out in the open because it's much more common uh and than people understand. And another thing that's very important uh to understand is that it isn't like one or two episodes. In our study, the average uh sexually abused girl was abused for about two years, once or twice a week. So we're talking about hundreds of episodes, and some of them it probably was in the thousand or something, or certainly many hundreds of episodes. Think about that impact on development. You it's just almost impossible to convey. I mean, our our the media models are a sort of a one-time trauma blows you apart. That's not what happens to these children. They're just beat on continuously by the both the maltreatment, but also the anxiety in between episodes. When's it going to happen again? How can I stay safe? Who can I trust? All of that uncertainty. So it really has very profound effects on their development. Um, how do you I think the most important thing is the validation. You don't have to validate specific episodes. It's more like I believe these terrible things happened to you and how are they affecting you now? And this is probably more important with adolescents uh than younger children. The younger children, it's very important to create safety and for them to feel safe. Uh, and they'll test that over and over and over again. How safe are they? How much do these people really care about me?
SPEAKER_01How will they how have you seen them test it?
SPEAKER_02Uh well, they'll they'll do all sorts of things, they'll act out in public, they'll uh trash the homes, they'll um, I mean, I you could probably give me more examples than I can give you. But uh, you know, this is what I hear, whereas I think you've seen it and heard it from many more people. But what have you heard about how they test? I mean, some of them, particularly the adolescents, could be very, very yes.
SPEAKER_01We yeah, we had um we fostered a couple teenagers, and um, both would fit into this category. Um, and the behaviors were epic. I mean, just absolutely epic. And and one of my jobs as their foster mom was to say, like, my line is safety inside of the house, and and short of safety, um, being an issue for other children. Um, like we have to make sure that the children in our home are safe, that everybody is safe at all times. Yes, yes, yes. Um, so that is that's a hard line, but short of that, um I I'm we're gonna figure this out. Like we can do hard things, we can do it together, right? Like this is um one explosive behavior is not gonna turn me away from you. I'm not gonna call your caseworker for this. That that kind of stuff where it's just um over and over again reassuring. And you know, there would be huge. I had one kid
who um loved to baker act herself. Like she would go to school and she would say the thing, and eventually her school would call me and they would say, I do not think that she is a danger to herself or anybody else, but she is saying these things, and so we have to do this, right? And I was like, Okay, like you legally have to do what you are gonna. She knows what she's saying, right? Most foster parents are not no, I don't want to say it like that. I want to say that there's an Assumption from the teenager that I'm not going to come pick her up in three days or four days, whenever that her time was up in the facility, right? Right. And I I would just be there in my car. Like, this is if that is how you are choosing to spend three of your days, like your schoolwork has has piled up in the back. Like I was very, very, very, very calm. And I think it was surprising to her every single time. Like, this is not um, it's not what I would choose, right? But she was she was poking to get a response. It's the test is to get a response, right?
SPEAKER_03We just and in lots of other ways.
SPEAKER_01It's like, I know that at some point you're going to disappoint me. I know that at some point you are going to leave me. So if I could just escalate this, I can get it over with before I get attached here, before I get like actually hurt.
SPEAKER_02Yes. That's exactly how I think about it. And and um unfortunately, they're very successful at that. I mean, they can just, it becomes a contest and they can just drive a foster parent, particularly one who's not experienced into the ground. You know, there's just a high rate of people taking one foster child and and then you know, no longer being a foster parent.
SPEAKER_01Yeah. 50%. 50% of foster parents close their license in the first year.
SPEAKER_02Is that right?
SPEAKER_01Yep. After the first placement or within the first year, but 90% will keep their license open if they're supported. So if somebody just comes alongside the foster parent and says, Hey, I see you, and it matters to me what you're doing, and I am here for you, like you're doing this hard thing, but you don't have to do it alone. Um, foster parents will keep their license open.
SPEAKER_02Yeah. Well, this is what I I think. And what one of the things that we tried to do was to help foster parents understand how trauma plays into these behaviors. Um, because uh the the trauma is it produces certain kinds of behaviors that are are are perplexing, difficult sometimes for foster parents to understand where they're coming from. Why is the child doing this? I mean, for example, it's hoarding. Uh I mean, have you seen hoarding where they hoard food and hide food? Oh yeah, yeah.
SPEAKER_01We fostered 23 kids and adopted a sibling set of four from foster care. So um we have definitely seen hoarding that is in our that's in our home. Tell me, tell me about that. Uh what's happening behind the scenes for them. Like explain it clinically.
SPEAKER_02Well, it's again, uh clinically, I think it's pretty that they just don't trust that things are stable. Uh and many of them have faced uh deprivation and and uh the pay they've had to look after themselves, and so they're gonna have their nest egg, so to speak. So this is what they can go to. And it's uh compulsive can be quite compulsive. Um and so they just keep hoarding and hiding and finding places, and the foster parents are you know finding food under the bed and that sort of thing. Um, that's just an example. Um, I I'd like to actually talk about
some of these examples because I think they're they're they're um uh and then also would I'd like to talk a little bit about uh intervention um that it's it's uh we developed to try to help foster parents and other people. We uh deal with traumatized children. And um great, let's do it. Talk uh do the first one. Okay, well, well, one of the things I started that study for is because I had been working with these adults who had this dissociative disorder, and they had in many many cases actually kind of fragmented cells. And I was looking, is there what's going on in children? We know that sort of children develop and consolidate their personality. How is the trauma affecting this and resulting in some of these outcomes? And one of the critical things is memory. And um, what you see in many really traumatized children is they have a lot of amnesias. They do not have continuity of memory, and so it leads to behaviors where they deny they've done things that they've been watched doing, uh, and then they get called liars, uh, sorts of things. Um I had a little notes. Yeah, what we call perplexing forgetfulness. Sometimes they'll know something and you'll say, okay. And then the next time you ask them to do this, they don't know it. It's like they've never heard of it. Like you're, you know, this is uh this perplexing forgetfulness. They can't tap into some of their experiences in a very controlled way. They sort of are there, but they can't always get to what they know. Uh, for example. So the teachers in school see this like, and they say things like, I know he, she knows the multiplication tables because she did them through six the other day, the sixes or tens or whatever the other day. And today she can't even do the threes. And so you see this perplexing uh access to knowledge uh that they have. And this is because um the trauma affects something we call metacognition or executive function, meaning it's and part of that is knowing what you know. You you uh when you face situations, you draw on what you know. But if you don't know what you know, you can't you know access stuff. And we we all do this to a certain extent. You go, oh my, I would have, I knew that, I should have, you know, whatever. Um, but uh this is really a problem for them. So they can learn something and then they can't use it, and then people see this often as oppositional behavior. Um and I don't know, can you think of examples that that that fit this?
SPEAKER_00I am literally trying to hold everything inside of me because Dr.
SPEAKER_01Putnam, you just landed on one of my biggest frustrations as a parent is this um, I know that you know this. I know that you know this. Like I've I've taught it to you, we've done this together, and then the next go-around is it's as if we never ever did anything together. Does that make sense?
SPEAKER_02Like, yeah, that's exactly what I'm talking about, and this is uh and it's so frustrating. And and the assumption is this is oppositional behavior, you're resisting me, you know what to do, and you're just not doing it. Yes, the kid, the kid can't get to it, they don't know, you know. And when I've worked with group homes and residential treatment, uh, this is the worst because the staff goes crazy about this. This is the third time I've told them what the rules are, you know.
SPEAKER_01I'm telling you, I am like literally, I'm holding back tears right now. Um, just because this is this is truly one of my one of my big frustrations, especially with a couple of my kids that I see this with, where I'm like, why are you why are you trying to act like this? Like it's it is it is so frustrating as the parent. Because it makes you feel like you're crazy. Like it's like I feel crazy because I know that we have done this, right? Or or I'm I was sitting in this is when it was actually really perplexing to me recently. I was sitting in a conference for one of my kids, and the teacher said, We know that he knows how to do this, he's just choosing not to. And I sat there and I was like, that that is not this kid. I've never seen him choose not to do something that he knows how to do. Like I've I've never seen it. And I think you're describing it perfectly. Like it's it's the executive functioning, it's the metacognition, it's the he could multiply to 10 last week, but not to three this week. That that exact thing, or he could read for him, it's reading, he could read this paragraph last week, but now he can't. He's struggling to say basic words that that would come in first grade, right? And he's said he's several years past that.
SPEAKER_02Okay, this is exactly what I'm talking about. So so this is this is a disturbance of memory. This is part of dissociation, and it's this inability to retrieve information that you may know. And this has sorts of all sorts of consequences, one of which is it gets called you a liar, it gets called you seen as oppositional. I mean, people react to it, they don't think that maybe the kid really can't think, can't remember this. Um, they they uh lose time, they they can't account for what they've done or where they've gone or what they've done or doing. Uh and they may say make up, they may confabulate in a sense, make up uh an answer. And again, this sort of gets them called uh liars. Um, another thing you see in these children is what I'd call sort of trance states, where they kind of just freeze or stare off into space or um don't uh uh don't respond. They're they're often sort of not terrible, not responsive. And they may do this in school, they get called ADHD, um that sort of thing. Have you had seen kids who sort of like just trance out on you?
SPEAKER_01Oh, absolutely. And and the diagnoses of ADHD is prolific in foster and adoptive circles. And and as you're talking, like it's because there's not other language for it, or or it's a side effect of the trauma, right? What did the chicken come first or the egg kind of question with ADHD? It is it is what we experience. It's um one time I asked my one of my kids to put something in the trash, and I literally counted the minutes, minutes that it took to go across the living room to the trash can without adding like a an additional. Hey, remember we're walking to the trash can, minutes it took. And I was like, okay, all right, that's where her brain is today. Like that's that's what she's working with.
SPEAKER_02Right. I think it's helpful to think of these kids as going into sort of different states of mind. And in these states of mind, certain things are not accessible,
or they have different responses than they might have in another state of mind. Um so that um they and there's a thing called state-dependent memory, which is what you're seeing when you're seeing the perplexing forgetfulness, is that the information is in one mental state and they're in another mental state, and they can't get to it. We all we all have sort of some you know variants of that. If you're at work, for example, and you think you're when I get home, I'm gonna do this, but when you get home, you can't, you don't even remember it. Get back to work, you go, oh, I should have done that. You know, that yeah. I mean, we all have little examples, but these kids have it massively. Um, you know, uh and it fragments everything they do. It makes it very hard to learn from experience.
SPEAKER_01As a parent in that moment, as as you're interacting with your child, right? And and no parent is perfect and no interaction, like interactions can have a goal, but like as long as we're kind of pointed in that direction, I call it a win most of the time because it's it's so often, it's so constant, right? If we were to pause as parents and and think in terms of this, like what state is my child in, or um there's a like a metaphor of spoons with for people who have like chronic illness or chronic chronic anything, where it's like, how many spoons do I have to work with today? If we were to pause and go, okay, I think we've got, I think we're dealing with two spoons. Like this is so I'm gonna parent here at two spoons. I'm gonna I'm gonna add more supports, I'm gonna add more structure underneath. I'm gonna assume that they're doing the best that they can right now in this state and come alongside them and build structure around them for this. Um, is that something that you would think would be super helpful? And I know that that's like a leading question because I just suggested a great parenting tactic.
SPEAKER_02But I agree with it. Um, I think the thing that's actually important is to actually look at it as a state. And and you'll, if you look at it as state, you'll see things in their behavior. It'll become more of a package. You'll see the way they walk, the way they talk, how they respond. Um, as you say, you know, how long it takes to get across you know, the living room or whatever. It's you'll see kind of a package of of behavior and and demeanor, uh, uh and you'll come to recognize it as a state. Uh, and rec and and I think one of the things is to try to help the child move what they know in one state into another state. So they begin to access. And and this is really an important caretaker function, is helping them bridge, you know, and that's where you say, remember where what we did here, remember, you know, what cues can you find to help trigger and help them access this? And it's persistence, it's patience, it's it's not taking this uh as an insult or as uh oppositional behavior. It's like, how can I help you get to what you already know?
SPEAKER_01As a way of curiosity, like I've I hear very curiosity driven in that. Do you remember like helping the the child with curiosity? Do you remember this? Do you remember where where do you think your socks might be if we're trying to get dressed for the morning or something like that?
SPEAKER_02Is that is that what you're yeah, you know, or what what do you you can you remember what you did with your socks, you know, or where you put this and and and helping the child sort of move around. I think as adults, we don't understand how fragmentary their lives are, and therefore how difficult it is for them to connect things up, you know.
SPEAKER_01So building sorry, go ahead.
SPEAKER_02I I was gonna go on to some other one one of the consequences is a kind of a fragmented sense of self, because if you're sort of all over the map and sometimes you can do something and sometimes you can't, you don't know how to trust yourself, you don't know whether you can do something, because sometimes you can and sometimes you can't, and you don't know what makes that happen. And and so you get a uh even sometimes them talking about themselves in a third person, uh you know, where they uh talk about, you know, Janie can do this where Jane is talking about herself or something. That's uh have you seen that kind of behavior?
SPEAKER_01Um I've seen fragmented, but mercifully not third person speak in in any of the kids. But I have had children who don't necessarily know how to proceed in a social situation, given that it's slightly different than the last one, or I could do this then, but I don't know if I can do this now. I can I can ask for a hug before I go to bed, but sometimes, sometimes like you know what I mean, that kind of sometimes I get more, I get less like, and then they don't, they they're frozen right there.
SPEAKER_02Okay. Have you have you seen frozen states? Oh, for sure. This is this is one of the things you see with these kids is kind of a frozen state or a very behaviorally disorganized state where they're sort of making strange movements or strange sounds. Um, you know, you know, and again, this is part of a larger
picture clinically, but again, people are reacting to you know, stop making that funny noise, or you know, straighten up and walk right, or you know, um that sort of thing. They they don't recognize that this is part of uh uh kind of a trauma behavior in children.
SPEAKER_01Yeah, we have had children um through the years of of fostering, and then even some of the ones that we adopted that will become an animal, they will respond as an animal. Yes, yes, yes, yes, in high stress situations, or that they beam as high stress.
SPEAKER_02So have you seen that in oh all the time. It's it's pretty much pretty common for many of the really behaviorally disturbed kids to have sort of an animal kind of become mute or respond, you know, bark or meow or whatever, um in response.
SPEAKER_01Yep, only they will only respond via barks or meows, or um, I have one that becomes a tiger. And um it's it's interesting. Those conversations with teachers at school are really interesting. I'll tell you that much. I'm like, I'm I'm sorry. I don't when she's when she's doing this, there's something else escalated, like there's something she's not able to talk to you right now as a human. And so we just remind her that she's a human and we say, Hey, can you put your feet on the ground or stand like you you kind of have to give the cues of what is behaviorally appropriate right now, but from a not abrasive um standpoint, honestly. Like it's they're in survival mode, some something has been triggered, and so you kind of have to really come alongside in those moments and just say, okay, you're responding like a dog. I think that you're probably trying to communicate that X, Y, or Z, like or like start giving them words, is what we have seen as successful.
SPEAKER_02Yeah, so that that's exactly what I would again say. I mean, it's it's you come to those sort of responses because they're the ones that seem to work best. Um and um but again, it's not deliberate in the same way that they're trying to rattle your cage. They they have retreated into that dog cat or whatever because they're overwhelmed in some way and they can't talk, and it's sort of like a mutism in a way. Uh again, we're talking about pretty traumatized kids. This is you know, obviously not that all that common, but these are the kids I've been seeing. Obviously, you have too.
SPEAKER_01I mean, when we're talking about children who are in foster care, we're talking about children who have been um abused enough to the point that the state is involved, right? That's that's exactly right. Abandoned or neglected to the point where the state gets involved. They're not coming in with without uh suitcases full of baggage here. And and I hesitate to even say it like that. What I what I normally say is like these children have lived more in their short lives than I have in 43 years. And still what I see is kids who are so determined to survive that they go the extra mile to make it happen. You know what I mean? Like kids who have this will to survive and and somehow have not lost hope for the future and and just kind of keep um they keep waking up and they keep trying the next day. And and when I can remember that as their mom, when I can remind other parents of that as like that, these kids have more determination in their pinky fingers than I have ever needed, because the odds have never been this stacked against me as a as a person, even with life events and and tragedies and traumas that I've experienced. It's never been like this. Um I what you we were talking about interventions earlier, and you had a couple that you wanted to mention. Do you want to do you want to bring up
any of those?
SPEAKER_02Um yes, I I think one of the things uh, you know, let me first sort of declare that I have no financial interest in these. I was involved in developing them. Um, other people have taken them and commercialized them to some extent. I think done a very good job with it, but I'm not involved in that part of it. But they do have a website and they do teach this and train train these interventions. But originally they were sort of developed by a group of us uh to help uh foster parents, was sort of my interest, but also teachers. uh who are dealing with traumatized kids, uh basically sort of non-clinical people who uh are dealing with sort of severe traumatized children. Um and they um their sort of best um the package uh is we call care uh it stands for child adult relationship enhancement it's just a simple the website is called i care it was a small i and then c a r e I think it's a com I I don't remember um but if you put in i c A R E dot whatever tricom try org um but it it's now out there as a commercial and we're training it to staff and hospitals and I actually no longer am involved in it but they're training it to staff and hospitals foster care systems uh school systems people who encounter traumatized children um and it's really a um a simplification of a set of interventions that were developed uh by somebody else a woman named Sheila Iberg uh who developed uh interventions called PCIT parent-child interaction therapy and that's a pretty it's it PCIT is very good particularly up to about age 12 or 13 uh it's not as good with adolescents but um the uh for for younger children it's it's a particularly um effective and it can take some very traumatized children who are really acting out destructive aggressive and and uh really turn things around pretty quickly it's uh it's very much a measurement driven by that I mean every session the therapist is grading the parent and the child interaction and figuring out what's going on the parent has to make certain numbers of appropriate responses before they move to the next level et cetera so it's um it's sort of driven by the the sort of learning rate of the parent uh it starts out with what we call a child directed interaction where the parent doesn't try or I say parent it could be foster parent could be the caretaker um where they don't try to actually control the intervention uh they just are following the child's uh response and so if the child wants to do something they they are really building rapport and then after the rapport is built sufficiently you move to a parent directed interaction where you teach the parent how to uh give good commands how to give good timeouts those sorts of things it's I've seen really really disturbed kids um fairly rapidly turn around so we took that which has a very big body of evidence for it if you go to their website and I have nothing to do with the organization I I simply see this as a really good intervention and and we we picked up on it and thought well how can we simplify this uh because the PCIT intervention requires many hours of sessions it's it's you know it's very effective but it takes time foster parents don't have a lot of time I'm sure you can tell me that um and so this was something that you could train in two three four hours I mean you could do it in an afternoon and with a group of foster parents uh andor with a group of teachers or something like that and it uses uh it teaches about how to give commands how to give good feedback uh how to handle certain kinds of behavior and it really is very much kind of operant conditioning you you look for the good things and reinforce them you to some extent ignore the bad things and you sort of build up uh a set of behaviors by particularly being very clear about what you're reinforcing we give what they call label praises for example you don't say good job you say good job putting away the toys that sort of thing uh simple pretty simple stuff but um it's uh pretty effective if you do it consistently um particularly with younger kids by the time you get to adolescence they they do it to you they pick they figure out what you're doing and they turn around and say good job mom you know doing this or that listen teenagers are incredible but one of the reasons is because they're as smart as you now and they don't they don't smarter smarter smarter I mean it is it has been fascinating watching some of my peers try to parent with certain um resources that are out there that work so well for younger kids and the teenagers eat it for lunch and they just are like that you're not coming at me with that business I um for have found a lot of success just treating teenagers with respect and being like hey you are you you have a brain I mean it's a developing brain but moving into a coach role right moving into like a hey here here are your choices each choice that we make has consequences and no matter what you pick I'm gonna be here on the back end and we can figure out whatever we need to figure out when we need to figure it out. Um obviously it's a little bit more robust than that but like just uh talking to them like they are intelligent human beings who have absolutely one of the things for foster parents unfortunately is that they don't have that long history of doing it with that child. So they can't like dig back to remember that time you were nine years old and you so and so they're often dealing with a child they hardly know at all uh who may also have other things going on. I mean we one of the things we did was set up a clinic just to handle their medical issues because they were just bouncing from doctor to doctor after these placements and the foster parents were having all these pills and they had no idea why he's taking this or why he's taking that or it was I mean the system is terrible in terms of helping support foster parents it definitely does not come without its challenges that is for sure um just one question um here at the end and I think
one of our things here at Haven is we're so focused on sustainability, right?
SPEAKER_01Like how do we create sustainability in foster care and adoption and for you to have this like long enduring career in psychiatry and and with um personality disorders and then sexual abuse victims that is hard that's hard to study it's hard those are hard facts to know how have you um maintained resilience to do the work and what keeps you going as you do this work?
SPEAKER_02So a question I often get is doesn't this make you depressed all these things are terrible and my answer has been for a long time you know just it makes me mad it's wrong it's it's not right it's you know you should not do these things to a child shouldn't do them to anybody but a developing child and um that's sometimes been really the sustaining thing that I just see injustice. And there's but but I want what I want to do is not just try to fix it but to prevent it on uh and so I'm very interested in prevention and and I've been involved in a number of those kinds of projects but but also help people understand it better because I think the problem with particularly trauma is that it leads to these behaviors that just lead to more traumatization. You know both being misunderstood is is very painful particularly as a child but also they there's a set of behaviors that just get them in deeper they get re-victimized um that sort of thing so they get re-traumatized and that's that's trauma's cumulative and anything you can do to prevent trauma is is really to the good yeah anything you can do to prevent trauma is to the good of not just the person in question but society as a whole right because we see oh yes of trauma in society as a whole and it is certainly um damaging this is so true you know if we could prevent maltreatment we would be doing so much about mental health we'd be doing a lot about physical and medical health because what we know is that these experiences actually shorten your life um and that's that biological accelerated aging piece that uh if you really have these experiences now i there's I think long-term good news about that in the sense that we're there's an enormous amount of work going on about aging and versatility of aging and we're beginning to see how aging affects things like the DNA and through things like the epigenetics some of these processes appear to be reversible. It's possible um that that you know things if we keep our medical establishment which I worry about a lot given what's happening to the scientific grants but if we keep that it's I would think in a dozen years or something we would be able to reverse a number of the uh effects on on the apogenine on the things that affect uh basically accelerated biological aging he we know that some of these processes are potentially reversible we just haven't have a lot of experience doing that we've just been marrying them for maybe five years now something like that um I remember reading about how victims of the Holocaust how they studied their children survivors of the Holocaust and how they had their DNA was fundamentally altered by the experiences that their parents had um yes this is epigenetics uh Rachel Yehuda's work and other people's work um I would imagine that there is an element of that at play here yes that that it's possible that they could actually that they could pass this down this kind of carrying trauma forward into the next generation without um if left unchecked I guess is the way that I want to say it that that's correct the the what the DNA that's being affected is what we call the epigenene it's sort of the structure which DNA the the base pairs are wrapped around the what we call histones not to get too deep in the weeds but what happens is that with time and stress you get a a process they call methylation that is essentially these these uh groups get attached to your DNA and they make it harder to replicate they cause more errors and and this is what we associate with aging and um it's possible to undo some of that and you know um but but it is possible to pass that on so that we have animal studies very clearly where you stress um maybe mice for example and um they will then have a altered uh sort of response to stress which they then pass on to their offspring um and you can do that to some extent with resilience also um and uh I'm pretty sure it probably happens with people also but we don't have a lot of evidence for that at the moment you just said you could do that with resilience well yes uh that is to some extent um there you can do things to like rat pups that make them more resilient to stress than um then so the same the classic experiment has been you've got a a bunch of rat pups just born they're dependent on their mother you take some and you put them uh take them out of their cage from the mother for 15 minutes and put them back in you take some others you take keep them out for three hours uh you take some that you never take out and you look at their their response to other kind of stressors and you see the ones that that are taken out for 15 minutes and return to their mother and their mother licks them and grooms them and and says welcome back they do well if they're out for three hours they don't do well and they actually pass that on to their offspring uh more anxiety more timidness uh and increased uh stress response hormones and uh you're sort of comparing everybody to the ones who didn't go away in the first place so a little bit uh you know leads to resilience too much leads to a vulnerability but resilience um resilience has found been found to be very impactful i i is what I'm hearing like that it's that the need for resilience is there and it produces stronger um yeah results we've when we've looked at resilience resilience is a tough thing people talk about it a lot but it's it's really a tough thing to sort of measure if I had to say what I think about resilience it's has a lot to do with relationships. What we see with um our cohort in that study
that's the sort of core of the book um is that the the for example the girls who had um relationships with older females who are healthy relationships they do so much better uh for example than the girls who had relationships with uh older males um and uh so that's we saw that the relationships are really very critical other things that have to do with resilience are harder to affect things like I mean one of the major factors for resilience is simply IQ um if you're the smarter you are really sort of the more options and the better chance you have another is being physically attractive that attracts people to you and helps you get relationships being um having a special talent or uh special abilities also increases your relationships but I mean I think basically most of the things we think of as factors that increase resilience act through increasing and improving relationships.
SPEAKER_01Yeah it's like trauma happens in relationships and it's also healed in relationship right yes relationships is really the big thing it's it's really the big thing um it's so so so important and that can put so much pressure um on foster and adoptive parents on to to like be at the height of performance all of the time as a parent you know and feeling um like they're never good enough they're not ever doing the job well enough because the the need is so great and the behaviors are so high and the the journey is so long right and so it's like how how I don't know I just as a foster mom I don't really even have a question here just more like it matters relationship matters and I think that I kind of want to just end end here in this idea that trauma happens in relationships and it can be healed in relationships and that it's possible to change the trajectory that that is ultimately like one of the things that you found right is that like we can we can put guardrails not and not determine the outcome but increase the chance the likelihood that we don't pass this down to the next generation that we don't become a perpetrator that that children who have been abused do not become future abusers.
SPEAKER_02So let me just put a statistic I've looked at that a lot because it's something that's very important to me to figure out how we can address what I always try to say is that the data are that most by that I mean two-thirds of abused children do not become abusive parents. It's really important that that people understand that I looked at this six ways to Sunday I mean I've looked at all the literature I've I and I have other ways I'm I intend to study it sort of my next project um but but about a third of them do. And that's about six times higher than people who don't have that parents who don't have that history of abuse. So there is a there is a relationship there. I mean it's it's a it's a powerful relationship that that uh abuse does beget abuse trauma does beget trauma domestic violence that that sort of thing um but it's not inevitable and it's not even the majority of times it's it's it's a third or less of the time um but it's it's something that we we sh have to be honest about that um and this is particularly true with males as perpetrators and females as failing to be vigilant and protective is is often what we see. Is there anything that we didn't talk about that you wish that we would have talked about I think we covered a lot I
really appreciated your jumping in and providing examples because you know I'm I'm um not a foster parent I actually intended to be but I I have serious medical problems so um it just wasn't gonna work um but it's um you know I I really really uh I really really respect foster parents and I really uh understand that they just have a very hard time in their you know just doing because these kids have more problems many more problems than kids in general and being a parent and I am a parent I have two grown sons and I have grandchildren um being a parent is difficult enough.
SPEAKER_01Yeah I I just would like to say Dr. Putnam you've done your part not everybody has to become a foster parent in order to help children who are in foster care and your body of work and the way you have dedicated yourself to to understanding and to helping and to providing um scientific and and clinical research behind um what parents and children are experiencing is is just really awesome. So um I wish I had a different word than awesome right there in my brain available to me because it's bigger than awesome. It is it is um a labor of love. Nobody gets this close to the details and keeps going um without it being a labor of love and the anger that you were talking about experiencing that the injustice that is happening that you have let that fuel you instead of turning you away um it's just really great to see and to to know that people outside of the community care just as much and and do their part in their own way.
SPEAKER_02So thank you so much for being on the podcast today thank you for all that I mean I as I you know say in the beginning of the book it's for me been a calling in in in many ways and that's kept me going uh despite whatever's happened. Yeah thanks for being here thank you