No fear: How traumas can impact on children's lives
FOR Caroline Williams, a shopping trip with her adopted daughter Emma would be seen by many parents as a nightmare. In WH Smith, the nine-year-old darts from her mother's view and is found helping staff stack shelves. In Sainsbury's she can launch in the arms of complete strangers simply because she has seen their face in the street.
Stranger danger - so ingrained in most children from a very early age - is not a concept Emma relates to easily. Hungry for affection which was denied her at the start of life, she makes everyone her friend - from doctors and social workers to old ladies and shop workers.
Emma has been diagnosed with reactive attachment disorder (RAD), a little-known condition caused by trauma in early life which can leave youngsters either overly friendly or distrustful of those around them.
Child psychiatrists in Glasgow believe the condition is under-diagnosed and have launched a research project to identify children with the disorder and ensure that they get the help they need.
Emma moved in with Caroline, in Glasgow in July 2007, when she was five-and-a-half, and was formally adopted in November 2009.
Her RAD was evident early on, and continues to affect the family's trips out, where every encounter can turn into an attempt by the little girl to make new friends.
Caroline said: "We were browsing in WH Smith and the woman was stocking up the pens and pencils.
"Emma went over and knelt on the floor and helped her. The woman was happy for her to do that and I was still in view as she did all the work with the woman.
"I've also seen her in the supermarket tidying up the sweeties and chocolate, and she will speak to shop keepers and ask them things.
"And last week we took our bikes into Halfords for a service and she wanted to stay and help the guys fix the bikes. I tried to explain that you couldn't do that unless you worked there and she kept saying 'ask them what age I have to be to get a job?' and she was really upset to discover she had to be 16."
While such behaviour may seem endearing, the willingness to lay herself open to perfect strangers also holds risks.
"I think if they had said she could stay and help fix the bikes she would have quite happily had me leave the shop and leave her there with the men, which is a bit worrying," Caroline said.
Emma suffered neglect and abuse from her birth family before eventually being taken into care. This troubled background has left a lasting mark in the form of RAD."There was physical abuse and aggression towards her, but also emotional abuse and that was quite obvious early on," Caroline said.
"She had very low self-esteem and she would say 'I'm stupid, I'm never going to have a happy life, I'm never going to have a good life and I am a bad person'.
"It is very strange for a five-year-old to think so negatively about herself and think she was to blame for everything."
When Emma went to live with Caroline she wanted to be carried all the time.
When Caroline saw her doctor's notes, she learned that as soon as Emma started to walk, she was never taken out in her buggy or picked up again and taken around in her reins.
"She was put in walking reins and was dragged around quite a lot," she said.
"There were incidents of members of the public complaining because of seeing her being mistreated in this way.
"So that is obviously why she wanted to be picked up because she had missed out on that," Caroline said.
Emma was also very close to the professionals involved in her care, such as social workers and health staff, seeing them all as friends.
"What she still sometimes does with adults is, when she sees them, she doesn't react in the normal way and say 'hello'.
"Instead, she runs and launches herself at them to be hugged and be held," Caroline said.
"She loves old women and she will cuddle old women that she meets.
"She did have a grandmother who I think must have been quite a positive impact in her life at some point."
Emma does not always find it easy to speak to adults - particularly if it is them initiating the contact rather than herself.
"There are occasions when adults will speak to her and she will refuse to respond and she won't open her mouth at all," Caroline said.
"If people ask her questions, it's almost as if she is worried about getting the answer wrong so she won't say."
One treatment for RAD is taking children back and filling in the gaps where they missed out at an early age which may have stopped them developing as usual, such as giving them toys to play with and caring for them like a baby.
"Emma did not have a lot of toys, she was given a phone book or an Argos catalogue to play with," Caroline said.
"The theory is that these kind of blocks are missing and so the children's personalities don't develop correctly.You can go back and put these blocks back in, such as by carrying her about," Caroline said.
"Another thing we did was the baby game, where she would pretend to be a baby and I would give her a bottle of milk and wind her and burp her, and she had a dummy and a blanket."
Dr Helen Minnis, a senior lecturer in child and adolescent psychiatry at Glasgow University, helped diagnose Emma's condition and is working to increase awareness of RAD among professionals working with children.
She became interested in RAD after working in an orphanage in Guatemala before she started working in psychiatry.
When she returned to Scotland, she came to believe that children closer to home were also showing the classic signs of RAD.
"One of the things that was really striking to me was that even though I initially recognised it in an orphanage setting, when I came back to the UK it was clearly out there in the population," Minnis said.
"Although foster carers and adoptive parents were talking about it, it struck me that there were kids out there who had not been recognised.
"In Glasgow, it has only really been the last few years that these children have begun to be referred to child and adolescent mental health services."
Minnis and her colleagues have been conducting research to find out more about RAD, including how it affects children and how many sufferers there might be.
RAD affects children deprived of food, love and security in the first years of life - often after the loss of their natural mother - and often develops in children placed in care homes or shifted between foster parents.
It can also affect children growing up in homes where abuse or domestic violence are everyday occurrences.
While the disorder is thought to be more common in children in the care system, it can also affect youngsters being looked after in their own families following neglect early in their lives.
"It is a disorder related to maltreatment or significant problems in the parent-child relationship in the early months and years.
"There are two different ways in which it can manifest itself," Minnis said. "One is where you have children who are quite disinhibited and indiscriminately friendly.
"They are children who will go up to anyone in the street and they don't have the normal stranger-danger feeling that most children will have, so they can put themselves at risk. The other way it can manifest itself is with children who are withdrawn and hyper-vigilant - they are wary and watchful even when there is no reason to be wary and watchful.They tend not to go to people for comfort.
"The thing that is interesting about reactive attachment disorder is that children with both these kind of behaviours tend not to distinguish between strangers and people they are intimate with."
Minnis, who will outline her project at a conference organised in Glasgow by the charity Mindroom next month, said a key problem in getting children like Emma the help they need is that aspects of their behaviour may simply not be picked up by professional carers.
"If you are a clinician and you have a child who comes in to your clinic for the first time and comes and leans against you, you might just think 'I am good with kids'," she said.
"So as clinicians, I think we didn't realise the significance of these behaviours and certainly our research has shown that these children do have quite significant problems."
Another concern is what happens to children with RAD as they reach adulthood. Minnis is worried they could face greater risks of being excluded from society.
"The research hasn't yet been done to follow-up groups of children into adulthood, so we don't know for certain," she said.
"But we do know that children with RAD have real problems fitting into social groups."
For Emma, the gaps in the care and affection so near the beginning of her life are now being filled thanks to the love of her adoptive family. But for many more children, their condition undiagnosed, the missing pieces remain as they struggle to decide who they can trust and who should remain a stranger.
• Caroline and Emma's names have been changed