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ARTICLES WRITTEN BY DR. ALEXANDER
 
  NEUROLOGICAL VULNERABILITY IN FOSTER AND ADOPTED CHILDREN: Strategies for Intervention

I first started administering psychological testing to foster and adopted children in 1992. I had just completed my training in child psychology, with much of this focused on the assessment of children's psychological status. As would be expected, I identified high rates of depression, posttraumatic stress, and anxiety in the children I assessed. Many of these kids had found their way into temporary or permanent homes without ever having been provided with a context or adequate explanation as to how and why this happened. Some were grieving for birth families--whether they actually knew or remembered them or not--and most of these kids felt they had to shed one identity and assume another. Training for foster and adoptive parents was pretty weak back then, and services directed toward this population of children was practically non-existent, even in the Bay Area of California where I did my training.

As our understanding about the psychology of foster care and adoption has grown over the years, we now have a better grasp on the role attachment plays in a child's development. Increasingly, we are also coming to appreciate that the psychological treatment of children yields better results when it is provided in a family context, rather than just meeting alone with the child week after week. With respect to psychological testing of foster and adopted children, more of them are being referred for this service, as families and providers appreciate the part it plays at pin-pointing aspects of the child's overall functioning and development.

In the years I have been conducting psychological testing with foster and adopted children and adolescents, certain themes have emerged. Many of these kids, for example, are immature relative to their peers. This makes sense on one level, in that it is not uncommon for children in the child welfare system to experience disruptions in basic aspects of their psychological development. While other kids their age were playing and attending the to the task of being a youngster, for example, many of these kids directed their attention to basic survival. Maybe they grew up in a household where there was abuse, neglect, substance abuse, domestic violence, or impoverished conditions. When this happens, children can't direct their efforts to age-typical activities such as play, as they are more focused on the immediate safety and well-being of themselves and perhaps those around them. Similarly, if a young child spent her early months or years in an orphanage, the hope of getting simple needs met and attended to likely consumed a good deal of her internal world.

In the assessments I conduct of foster and adopted children, I also find high rates of intellectual and neurological delays. This isn't too surprising in some respects, given that parents don't typically seek my services unless their child is presenting with ongoing emotional, behavioral, or learning difficulties. Though blanket statements can rarely be made about any group of people, foster and adopted children are at higher risk for manifesting developmental delays given the circumstances and reasons that result in them living apart from their birth parents. Put simply, poverty, poor prenatal care, prenatal exposure to toxins (alcohol, drugs, tobacco, or lead), premature birth, birth trauma, and/or post-birth neglect, abuse or trauma takes a toll on a child's neurological and physical development. Certainly, these effects won't look the same in all children, but it is a mistake to ignore the implications.

Despite all the advances made in medicine, babies born eight or more weeks early, as well as those who were exposed to toxins in-utero, remain at risk for many mental and neurological problems, including visual, hearing, and motor deficits, poor emotional regulation, attention problems, and language delays. For example, by grade school, children who weighed less than four pounds at birth--most of whom were born premature--perform more poorly in school and score about six points lower on IQ tests than children born full term. As Daniel Siegel points out in his book, The Developing Mind (1999), trauma and neglect in early childhood can actually inhibit adequate growth of the brain: "...early life history of absence of any attachment experience (as in severe neglect) or the experience of overwhelming trauma (as in physical, sexual, or emotional) may markedly alter the neurobiological structure of the brain in ways that are difficult, if not impossible, to repair." Thus, a child's behavior, personality, and brain functioning is not just influenced by attachment, but by biology, genetics, and life experiences.

Alcohol

With respect to alcohol and drug use during pregnancy, the results are very concerning. Prenatal alcohol exposure is one of the leading causes of mental retardation, and it readily crosses the placenta. Thus, if a mother is intoxicated, her fetus is drunk as well. In addition, alcohol directly kills neurons in fetal brains.

Marijuana

Marijuana use offers the double-whammy of a drug effect and the oxygen deprivation caused by smoking. THC, the intoxicating chemical in marijuana, crosses the placenta and is cleared very slowly from the fetal circulation. Like tobacco, marijuana greatly increases carbon monoxide levels in the fetus' circulation, robbing the developing brain of necessary oxygen. Maternal marijuana use has been linked to altered visual and startle response in newborns, to behavioral deficits in school-aged children, and to verbal and memory deficits in toddlers.

Cocaine

Cocaine does not produce any particular pattern of fetal malformation, but it is associated with gestational problems that interfere with normal brain development. Babies of cocaine-addicted mothers tend to be small, whether or not they were born prematurely. After birth, cocaine-exposed babies don't respond well to their environment or interact normally with caregivers.

Cigarettes

Whereas society ranks drugs from 'okay' (cigarettes) to 'not okay' (cocaine), the impact these substances has on the developing fetus is the opposite of what would be expected. Many children born exposed to cocaine or heroin, for example, do not present with noteworthy physical or psychological complications. When a mother smokes, however, the effects can be quite significant. When a pregnant mother smokes, nicotine rushes into the fetal circulation and dramatically alters the baby's breathing movements, with periods of apnea. Several long-term studies of children born to mothers who smoked during pregnancy have suggested that their brain development and function are compromised. In various reports, prenatal smoking has been linked to deficiencies in newborn sucking ability, in language and motor skills in infants, in hyperactivity and auditory attention in young children, and in learning ability in school-age children. In studies of animals and children, prenatal exposure to tobacco contributes to behavioral deficits, which can present as ADHD, oppositional and defiant behaviors, and poor emotional regulation.

Implications

Unfortunately, I don't believe that adequate attention is directed by many professionals toward the child's prenatal experience in the course of conducting an interview or assessment. In addition, it is not uncommon for me to read reports by my colleagues where no tests of cognitive ability or function were administered. While this might be permissible in some instances, I firmly believe that the assessment of all foster and adopted children must include some measure of cognitive functioning. Otherwise, there is a tendency to attribute all of the child's difficulties to attachment or psychological factors. While these attributes are important, the magnitude of brain compromise I see with this population of children points to the importance of broadening the nature of interview questions and testing procedures that should be integrated into child assessment.

When an adequate assessment is conducted, and if neurological vulnerability or compromise is shown to be present with a particular child, this has significant implications with respect to treatment. If a child is having problems at home or school solely because of emotional factors, family counseling and perhaps short-term use of psychotropic medication may be indicated. If a child's struggles are due to neurological reasons, however, it can be a set-up for parents, teachers, and the child himself to rely upon charts, rewards, positive reinforcement, and expectations of self-control. Think of a situation where an adult has a head injury or suffers a stroke. We might find the behaviors and personality changes that result from this problematic, but we usually have realistic expectations with respect to issues of change and recovery. By ignoring the part a child's brain plays in their behaviors or emotions, we deny them this respect.

Too often, parents and providers expect that psychiatric medication will tackle and address the emotional and behavioral problems of children in their care. Whether the brain is compromised or not, this is simply unrealistic. Take the example of a person with diabetes. The use of medication with diabetes can be helpful, but in most instances, simply using drugs alone will not help the person gain control of their condition. Instead, they must also pay attention to diet, exercise, and other health factors.

There are a variety of reasons why a good number of foster and adopted children are prescribed drugs. First, ours is a society that wants to believe there is a pill for almost any condition; second, insurance providers would much rather pay for the cost of a psychiatric consultation and a prescription than for more costly interventions such as inpatient treatment, intensive psychotherapy, or neurological rehabilitation; third, many foster and adoptive parents will tell you that the behavior their child manifests is simply bizarre, if not outright dangerous. This can include lying, stealing, fire play, animal cruelty, sexual precociousness, violence, dare-devil acts, and self-injury. When parents witness this, they desperately need an intervention that will help calm or settle the problematic behaviors. The thought of waiting weeks or months for therapy to 'kick in' isn't an option, and thus, medication is often requested.

There are certainly instances where medication can be useful with children. When the child's behavioral and emotional struggles are due to brain compromise, however, medication may have limited effects. Instead, brain compromise requires a variety of proactive efforts on the part of the parents, which often includes intensive advocacy for their child, particularly in school. Sadly, this isn't what many parents are prepared to hear, and especially in instances of foster care, the care provider may not believe it is their responsibility to work so hard at trying to manage or redirect the child's actions. As I have written elsewhere, some adoptive parents have attempted to sue the agencies that placed the child in their care, citing the unanticipated medical, psychological, and educational costs associated with raising a child they weren't told had special needs.

Interventions

No book or article can offer the right answers for each possible situation that can arise in the day-to-day life of a child. Instead, parents can learn ways of being with their children that promotes the development of empathy and compassion, while also affording opportunities for social, emotional, and academic success. The following suggestions are those I have found to be most useful with the clients and families with whom I work:

1. Learn about your child's condition. Make sure she receives a comprehensive assessment, which includes psychological and cognitive testing. If one has not been completed within the past year or two, request an updated one.

2. Many children with brain compromise have noteworthy deficits in the areas of short-term memory and attention. Regardless of their age, only offer one directive at a time and do it at eye level. If necessary, ask the child to repeat back what you asked. Only ask the child to assume responsibility for things they can realistically do.

3. Brain compromise, as well as psychological variables, can affect a child's emotional age. Don't belittle the child, but try relating to them at their emotional, not chronological age. They will feel less confused by what you say, and they will find your words more supportive. You will also experience less frustration if you recognize that your 14-year-old really functions closer to that of a six-year-old; would you ask a six-year-old to clean their room without offering proper supervision and assistance?

4. Meet with teachers and explain what is going on with your child. They do not need to be provided with extensive details about the child's history--especially if they reside in foster care--but let the teacher know what to anticipate behaviorally. Share with the teacher the strategies you have found to be effective at anticipating, redirecting, or managing the child's behavior. Also, make sure your child is in the right class. Some kids simply need a more experienced teacher or even an adult male teacher in order to do well. It is not fair to the teacher, the other students, or your child to maintain him in a class where his needs cannot be addressed.

5. The Individuals with Disabilities Education Act of 2004 [www.idea.ed.gov] mandates early intervention services for special needs kids. This includes psychological and social work services, speech and language services, occupational and physical therapy, special education programs, in-home living assistance programs, and transportation services. Especially in small and rural communities, the school may fight you to the end on this one. It costs them money and resources, which they will tell you they don't have. If necessary, consult with or hire an attorney.

6. Try 'brain-strengthening' exercises. This can include the use of logic puzzles, which can be found in the bookstore (in the Game section) or on-line. Also, ask your child to explain their understanding or rationale for easy and complex decisions (e.g. "Why do we ask kids not to talk to strangers?" "Why do we give you chores?"). Gradually shape their comprehension of social concepts.

7. Encourage all providers to collaborate with each other. Too often, the therapist doesn't talk to the psychiatrist; the psychiatrist doesn't talk to the teacher; the school social worker doesn't talk to the parents.

8. As the child grows older, focus more on adaptive functioning. When he is a teenager, your child can get away with having poor math or reading skills. Unless he can take care of basic needs, however, he'll be unable to live independently. Don't wait until he is 16 to address these matters. Identify the goals and make sure the school works with you at shaping these.

9. Only place the child in therapy that takes into account her cognitive, social, and physical functioning. Too often, these kids are enrolled in 'talk therapy,' which may not do much good, given its focus on asking the child to reflect on their behaviors or life.

10. Talk with other parents whose children have similar behaviors or conditions. They often have useful tips, and if nothing else, the support they offer is valuable. Taking care of a child with brain compromise--either on a short- or long-term basis--is extremely trying. You need to have adequate support in order to help you recognize which actions the child has control over, versus which ones he doesn't. Too often, parents of these kids think the behaviors are deliberate, when in fact, the child has no conscious control over them.

COMMENTS? alexanderphd@msn.com






SIBLING PLACEMENT: Trends in Adoption
Sibling Placement Trends and Studies

Currently, it is estimated that there are over 550,000 youth in foster care in the United States, with upwards of 85% having at least one sibling and 30% having four siblings or more. Yet, studies consistently show that approximately 75% of siblings end up apart when they enter foster care. Increasingly, the trend is to place siblings together unless doing so results in the risk of physical harm to one or more members of the family. Gordon Johnson of Jane Adams Hull House in Chicago writes, “Splitting up siblings is the most serious problem in our child welfare system today.”

A greater number of former foster children are searching for their siblings than are searching for their biological parents. They are suing child welfare agencies in order to get them to release information and they are winning.

State legislatures are also weighing in on the matter, thereby mandating courses of action in sibling placement cases. New York City, for example, has been under court order to place siblings together (unless contrary to the siblings’ health, safety, or welfare) since 1993. New York State law and regulations make clear that placement together with siblings is presumptively in a child’s best interest. California’s legislation regarding sibling placements is the most specific in the country, covering requirements to consider siblings at every stage of the placement process, steps that courts and agencies must take and requirements for documentation, provisions for post-adoption contact, required training for adoptive parents, and recognition of the need for placement resources. In Massachusetts, judges have ruled that agencies must accept responsibility for the failure of sibling groups to remain together. The Massachusetts decision added that “brothers and sisters should be raised together—even half brothers and sisters—unless there are compelling reasons for separating them.” In January 2008, Indiana Senator, Mike Delph introduced legislation that would allow children in foster care to request sibling visits; if Child Protective Services denies the request, the child and/or his/her advocate could petition the juvenile court to intervene.

In her book, Adopting the Older Child, Claudia Jewett writes, “Children separated from brothers and sisters may never resolve their feelings of loss, even if there are new brothers and sisters whom they grow to love. There may be more drive in adopted adults to track down their remembered biological siblings than there is to locate their birth parents, so great a hole does the loss of a sibling leave in one’s personal history.” Adoption specialist, Carolyn Johnson writes, “If the idea of the child welfare system is to protect and help children, everyone involved should be careful to carry out that mission and always keep in mind what the best interest of the child truly is.”

In 2002, the National Leadership Symposium on Siblings in Out-of-Home Care brought alumni of foster care, resource families, researchers, practitioners, advocates and policy makers to address sibling issues from a variety of perspectives. The findings were issued in a document, dated May 19 – 20, 2002. The Symposium developed several policy statements, including:

"...Bonds between siblings are real and strong, and may be stronger than the bond between parent and child. Yet sibling bonds are often discounted, particularly when there is a large age difference or when separation occurs. Maintaining sibling relationships

• Is a part of family preservation;

• Should be considered in both initial placement decisions and occasions to reconnect brothers and sisters who have been separated;

• Should be considered in post-permanency planning and supports, whether in reunification, adoptive, or other permanent placements; and

• Should play a role in independent living services for youth who age out of care.

Siblings placed together in out-of-home care can provide a feeling of connectedness to family, identity, and culture for one another, and older children can serve as mentors to younger siblings. Siblings can serve as one another’s compass for culture to help maintain cultural heritage (including family traditions) in a new home.

In 2002, the Youth Leadership Advisory Team issued a position paper on siblings in foster care and adoption. This includes:

"When youth are separated from their family by court order, they should have a right to continue to live with their siblings unless this is determined to pose a specific danger or is not in the best interest of the youth. Sibling contact provides continuity and family stability during the separation from home and family … They share the same heritage and biology, unlike any other relationship. The sibling relationship is unique and should be fostered in its own right."

The National Clearinghouse on Child Abuse and Neglect offers:

"Separating siblings in foster care or through adoption adds to their emotional burden. They have already had to cope with the separation and loss of their parents. If they are then separated from their siblings, they must experience the grieving process all over again. For many children, this separation will be even more traumatic because, if they have experienced abuse or neglect at the hands of their parents, they will often have stronger ties to each other than to their mother or father."

Finally, Casey Family Programs, include in their policy statement on sibling placement:

"Our reading of the literature, our experience at the Symposium, and our ongoing contact with both individuals who come to us for information and assistance and the colleagues who continue to work on sibling issues leads us to a series of beliefs about working with siblings in out-of-home care…We believe that it is essential to place children with all siblings who are in care and maximize their ability to maintain all family and community connections."




WELCOME HOME: A Guide for Adoptive, Foster & Treatment Foster Parents
Welcome Home: A Guide for Adoptive, Foster and Treatment Foster Parents

ISBN: 0-9754144-0-2

SAMPLE CHAPTER:

COUNSELING ISSUES FOR FOSTER AND ADOPTED CHILDREN



I believe that one of the main reasons child therapists often hesitate to allow parents to observe them is that they are basically ashamed of what they are doing.

Richard A. Gardner, 1993


Many parents are mystified by counseling and therapy. While they believe it holds the promise of helping their child, they often find themselves confused about what it takes to change troubling attitudes or behaviors. One of the realities about the mental health field is that a good number of clinicians who work with children never received formal training and supervision in this practice. Most graduate programs in psychology, counseling, or social work require students to take a course or two on human development or family dynamics. Yet, more detailed aspects of doing therapy with children are not typically included. I also find that a large number of clinicians who supervise other staff or interns in family service agencies were not trained as child therapists. They do not always ensure the therapist adequately includes the parents in the treatment of the child. I consistently find that parents become frustrated with the therapeutic experience when they feel excluded from what is happening between the counselor and their child.

An unfortunate trend in the treatment of foster and adopted children is to assume that all of their behavior or emotional disturbance stems from disrupted attachment. As I emphasize consistently throughout this book, issues of attachment and bonding are paramount for this population of children. But to assume the child’s presentation resulted from attachment problems is irresponsible. A child’s behavior can be motivated by a variety of factors. This includes features that are common to all children, such as temperament. Other factors include the more unique issues that many foster and adopted children are at high risk for, such as prenatal exposure to toxins, a family history of mental illness, or traumatic stress.

Prior to developing a treatment plan, it is important to understand all we can about the child’s history, behavior, and mental status. Too often, children are referred to me for an evaluation because the therapy they are receiving is not working and the provider wants input about what may be useful. I believe that the child’s needs are best served if the evaluation occurs before therapy is implemented. This evaluation can help determine whether issues — untreated mental illness, attention problems, neurological damage, or mood disturbance — require intervention before therapy begins.

Therapeutic intervention with foster and adopted children requires specialized training and experience. I am concerned when therapists who have no direct experience with this population of children provide counseling to them. I frequently find that therapists who lack the proper training do not adequately address issues of relinquishment, grief, anger, fear, and the attachment issues so common with these children. Nor do they fully comprehend the complexity of the child welfare system and how this affects the child and the family. In many instances, parental concerns go unaddressed or ignored when the therapist chooses to only work with the child. In situations where the child has severe attachment disturbance, my experience is that the child — not the therapist — is typically in control in the therapy due to unfamiliarity on the therapist’s part of effective interventions with this population.

Parents should feel comfortable interviewing prospective therapists in order learn about their experience in working with foster or adopted children. You will also want to find out how they will communicate the key issues of the treatment to you and how they identify treatment goals. If you are unaware of therapists in your area who specialize in treating foster or adopted children, check with various placement agencies in your region. Many adoption and attachment websites also have resource lists of therapists throughout the country.

When providing counseling for a child, it is important to explain to him the rules, parameters, and expectations. It is unrealistic to expect a child to come to therapy each time and talk about feelings or life experiences. More often, children need to be guided toward this goal. They also must understand, at their developmental level, the importance of talking about these issues. When providing therapy to a child and his family, I do an introduction to therapy, explaining how I work and why I explore the feelings and topics that I do.


Play Therapy

Therapists who have received training or education in working with children typically get exposed to what is called the play therapy model. This model suggests that play is the natural mode of communication for children and encourages interacting with the child in a playful manner during therapy. This might include playing board games, permitting the child to draw or build scenes in a tray of sand, or making a project together. In this approach, the therapist provides the child with many avenues for play — toys, clay, dolls, puppets, paint — and the child is usually free to use these things as he sees fit.

The basic premise of play therapy is twofold. On the one hand, it is believed children will exhibit the dominant themes of their inner life — anger, sadness, abandonment, abuse — through their play, thereby permitting the therapist to identify the child’s significant issues. The therapy becomes an avenue for symbolically expressing what the child feels. On the other hand, play therapy assumes that a trusting relationship may develop between the therapist and child, thus making him feel he can eventually share his feelings with the therapist. Play therapy often provides children with feelings of mastery, as they have the freedom to create and express themselves in many ways.

Play therapy can be an effective technique for many children, but I generally do not support or recommend it for foster or adopted children, particularly in cases where the child is having extreme behavior problems, adjustment reactions, or difficulty bonding to the parents. Rarely do I employ a play therapy model unless I am evaluating a young child or providing therapy to someone four years of age or younger. By the time many foster or adopted children are referred for counseling we often have a good idea about some of the major issues they are dealing with. This could include issues of abuse, neglect, abandonment, parental loss, betrayal, attachment, or changing homes.

While foster and adopted children should have ample opportunity for play, I don’t believe that therapy is the time for it. By the time a child is five or older, he has some capacity for using his words and turning his attention toward his behavior and relationships with others. Rather than have a child play with me for an hour, I would rather address key issues affecting his identity, behavior, and his peer and family relations. This doesn’t mean that the interactions between the child, parent, and me are not fun and playful at times. Yet, the child and parents are given the message that therapy is a time to take a close look at significant matters of the child’s life. This entails going after these issues in a more direct manner.

I will sometimes engage the family in an activity such as throwing and catching a ball, role-playing, or doing a group drawing. But, I do not find this should be a prominent part of the treatment. Certainly, playtime allows me to obtain information about how the child does with competition, cooperation, spontaneity, and limit setting, and occasionally proves useful to take a break from the intensive work of therapy. But I remind the children with whom I work that therapy is mostly a time to address the important issues in their life. If they are coming to me for treatment, there are usually legitimate concerns about how the child is feeling or behaving. The therapy must work toward understanding and modifying these as needed.

An exception occurs when there is not a clear idea about what feelings or issues a child is dealing with. If the parents are not sure what their child is experiencing inside or if the child is not verbally expressive, play techniques can help the therapist gain some perspective on the child’s needs. Play therapy has more value as a diagnostic tool than for treatment. Once the child’s issues are made clearer to the therapist, I still believe it best to move toward more proactive efforts in the treatment.

Many children are not motivated to participate in therapy, mainly because they are more focused on the present than on the past. Rather than look inward, most children will act out their feelings. While much of this will show in play therapy, rarely do I find that this results in significant changes in attitude or behavior. If therapy is to succeed with a child who is not motivated, then other techniques have to be used to engage them.

Parental Involvement

A man who, along with his wife, will be adopting the 15-year-old girl who has lived with them the past seven months told me recently:

"She’s been in therapy with the same therapist for close to two years. But this therapist isn’t giving us what we feel we need in order to work with our daughter. We went through the education classes offered by the adoption agency, but they haven’t prepared us for what we’re experiencing at home. We desperately need some guidance if this adoption is going to work out for all of us."

Since a primary goal in treating foster or adopted children is to address issues of their behavior, emotions, bonding and attachment, parents should be involved in the treatment. The therapist and child should meet alone at times, but by and large, I advocate parental involvement. I tell parents that their job is to work as my co-therapist, both in and out of therapy, as we address the important issues affecting their child’s life. The parents and I work as a team, trying to explore the child’s thoughts, beliefs, and actions. Also, the parents and I mutually address the problematic behaviors of the child, effectively communicating our interest in seeing him “make it.” I rely upon the parents to clarify any lies or omissions the child tells me about his life, as parents quite often have a better grasp on the full story. I consistently find that parents view the therapy as a worthwhile endeavor when they are included in the process.

As I stated in the introduction, parents are the front line of defense to help the child. Even if the child works with an excellent therapist, he won’t likely make many changes or gains if his efforts aren’t encouraged and supported in the home. When parents are included in the therapy, they have clearer ideas about the therapist’s goals. Parents are also in a better position to take what was practiced or discussed in therapy and use it at home.

When actively involved in the treatment, parents come to recognize and appreciate that growth and healing is not a linear process. It is well-established in the counseling field that children and adults will make strides in therapy but also experience relapses or dips. This doesn’t mean the therapy isn’t working or that the client is not motivated to attain their goals. My experience shows that parental involvement in the treatment helps them understand this reality, without getting angry at the therapist or losing faith in their child. Instead, the parents and I can talk about this fact while the child is present, assessing why this is occurring. For example, by brainstorming on the issue, we can become more sensitized to the hard work the child has been doing, the stress he may be experiencing, or to other issues affecting the child’s life.

I know from my own experience that I can do little to modify a child’s attitude or behavior without significant parental involvement. This is especially true with children who are assigned diagnoses such as Oppositional Defiant, Conduct, Reactive Attachment, Bipolar, or Attention-Deficit/Hyperactivity Disorders. Many children can focus their attention or contain their erratic behaviors when in a therapist’s office. But, at home and at school it may prove more difficult. Talking with a child about behavior I have not observed has a vague and abstract quality to it. But, a parent who lives with these behaviors on a daily basis introduces a more realistic aspect to the discussion. I am then in a better position to help the child examine his behavior, while also offering realistic interventions to the parent.

I do not believe that every foster or adopted child will develop significant attachment issues. But, this population of children holds a greater risk for attachment disturbance, which is one of the reasons their referral rates for mental health services are quite high. The research is fairly consistent in identifying greater rates of attachment issues among children who experienced abuse, neglect, or trauma at a very young age. By gaining an understanding of the dynamics between the parent and child, I am better able to determine to what extent the child’s behaviors are attachment-based, since disrupted attachment directly affects all of the child’s relationships. This may not be as evident if I am just meeting with the child alone.

As Daniel Hughes writes, maintaining an emotional engagement with the child, regardless of the behaviors manifested during treatment, is the foundation of all therapeutic interventions with the poorly attached child. Each session models ways to maintain a connection with the child in spite of the various misbehaviors in the home. Parents should see and participate in these models, particularly if they are feeling frustrated and angered by their child. By participating in the child’s therapy, parents learn techniques for engaging him in ways that don’t result in a power struggle. When observing a parent and child, I can also see how they play off one another or how the child responds to what the parent says or does.

If your child is seeing a therapist who does not include you in the process, you should have a good idea about what is and is not happening in therapy. Parents frequently sit in the waiting room while their child is in therapy and receive little information about the therapeutic goals or processes affecting their child. Unless you are seeing significant behavioral changes in your child at home and at school, I encourage considering alternatives to this approach. Therapists, too, will find that parents are more receptive to their recommendations if they are included in the process.

I do not believe that confidentiality should play a major part in the psychological treatment of children. If a therapist tells you that what he and the child discuss is confidential, I encourage you to exercise caution in working with that provider. Confidentiality is fine in the treatment of a 16-year-old, but not in therapy with a nine-year-old. As child psychiatrist Richard Gardner says, telling a child there will be confidentiality creates a structure of “we” (the therapist and the child) and “they” (the parents). “We” and “they” can easily become “we” versus “they,” which can create further conflict for the family. In order for child therapy to be useful and effective, parents should know about and appreciate the issues affecting their child. Most children do not have a great many secrets they wish to keep secret from parents. The exception might be in areas of abuse or other forms of parental maltreatment. Therapists who permit children to confide their stories often do so under the guise of building a trusting relationship with the child. I contend that this is counterproductive and ends up doing little to help the child or his family.

Parent-child interventions are also more likely to yield greater information about the child’s Internal Working Model, a concept introduced in the section on attachment. As Terry Levy and Michael Orlans note, the child’s internal working model includes core beliefs about self, caregivers, and life in general. This internal working model serves as a blueprint for all current and future relationships. Parents should attempt to understand the internal working model of the child they are raising. The thoughts a child has about himself influence all aspects of his life. Modifying negative internal working models of foster and adoptive children is a large part of the therapy but requires the active efforts of the therapist and the parents. Many of these children grow up believing that adults cannot protect them, that parents cannot be trusted, that they are destined to be “given away,” and that the world is unsafe. Therapeutic efforts must be directed at challenging, confronting, and attempting to re-work these beliefs. Otherwise, most other interventions with these children will fail.

Does My Child Have to be in Counseling?

Particularly with placements arranged through state social service agencies, parents are sometimes told that their child must be in counseling. In some situations, the child may have been in counseling while in one placement and the former therapist recommends continued treatment once the child is in a new placement. My opinion is that the decision to start a child in therapy should be a thoughtful one. Not every child needs counseling, even if they have a challenging past. Therapy can be helpful for children, but parents need to carefully consider when and if to start this process.

Within their new families, children should experience the rituals, behaviors, and routines that facilitate a respectful, loving, and trusting relationship. The initial weeks and months of a new placement can be fragile, as the parents and child get to know one another, and as the child struggles with feelings that may include excitement, fear, anger, sadness, and confusion. When children are brought to therapy during the early stage of the placement, I sometimes find that it can interfere with the bond that needs to develop between the parent and child, particularly in cases of adoption. As with parenting, therapy is a highly intimate and personal encounter. In order for counseling to be effective, the therapist must establish that his office is a safe environment for the expression of all kinds of emotions. The therapist needs to communicate that therapy is not a place for keeping secrets and that most aspects of the child’s current and past experience will be explored in depth. Therapy with foster or adopted children is not a short-term proposition, unless forced so by nature of the fact that the child’s placement changes. The therapist and child develop a unique relationship, where boundaries, emotions, and trust are constantly challenged.

In order to deal effectively with these dynamics, it is best if aspects of an intact relationship between the parent and child already in place. Allow me to use couples counseling as an example. While many couples could benefit from guidance and advice at the onset of their relationship, it is difficult to do actual therapy with a couple until they have been together for a while. Only when problematic themes and patterns of behavior have been identified can alternatives be explored. This analogy holds true in the treatment of children. Also, if a parent takes her child to therapy immediately after he arrives in the home, it sends the message that the parent does not have the knowledge or ability to tackle matters on her own. This can diminish the positive views the child needs to have of his parent.

In my experience, the intensity of the therapeutic relationship can make the child feel confused, as he develops a relationship with the therapist while also building on the one he has with his parents. In these instances, the child often strengthens ties to the therapist. For one thing, the therapist places less demand and expectation on him than do the parents. Many parents also communicate to him their desire to have the child love them unconditionally. A therapist does not impose this on the child, thus becoming less of a threat to his psychological defenses.

Attachment Therapy

Within the fields of counseling and psychology, there are mixed definitions about what constitutes attachment therapy. If your child is seeing a therapist who tells you they work on an attachment model, you should fully understand what they mean by this.

In a general sense, attachment-based approaches assume that the relationship a child has with others is influenced by his history of trauma, abuse, or neglect. Attachment disturbance in children is sometimes referred to as a relationship disorder. In light of this, the bulk of therapeutic interventions deemed attachment-based are directed toward strengthening the relationship the child has with others.

In most attachment-based therapies, children are encouraged to express the full range of feelings, to include the sad, the mad, the scared, and the glad. Parents, too, are supported in expressing the feelings they have about the child. To reduce feelings of vulnerability that can come with the expression of raw or intense emotions, therapists who work on an attachment model will periodically offer the child supportive touch, hugs, or holding and will encourage the parents to do the same. For example, as we’re talking about a particularly difficult time in the child’s life, I may place my hand on his shoulder or ask that he cuddle up with his mother as we talk about the issues. Touch is a powerful form of communication, yet for too many children touch has been hurtful or exploitative. Various forms of touch are often integrated into attachment therapies, something that has its advocates as well as its critics. In some instances, touch has been forced on children in therapy, making them feel further victimized or afraid. I always point out to the child in advance that I will sometimes touch him, yet I emphasize that his parents will be in the room when I do, that he can tell me “no,” tell me to stop, and that I will not hurt him.

As mentioned earlier, many children will regress in therapy as they explore feelings related to their past and present. The child will use words or actions that are common to much younger children, such as curling up in a fetal position, thumb-sucking, having a tantrum, using self-soothing behaviors such as stroking his hair, holding a small toy, or talking like a baby. In attachment therapy, these behaviors are supported. During a child’s regression, I will ask the parents, “What age does this behavior look like to you?” Their responses are usually correct and it helps us both understand the emotional age their child reverts to when he is feeling afraid, sad, or stressed.

In many respects, attachment-based therapy is a re-parenting process for the child. In treatment and at home, he is offered the nurturing responses and interactions he may have missed out on in earlier years of his life. While not done in an offensive or belittling way, the parent and therapist relate to the child — regardless of his age — as parents often do with infants. This includes tolerating a broad range of behaviors and emotions, permitting the child to safely act out his fears or frustrations, using lots of playful touch and physical interaction, and assuring the child of his safety every step of the way. If you watch a parent interacting with her infant, it is usually more playful and hands-on than with her older child. Attachment therapy takes the meaning this mode of interacting has for the child and brings it into the treatment.






THE INNER WORLD OF THE ADOPTED CHILD

THE INNER WORLD OF THE ADOPTED CHILD

Christopher J. Alexander, Ph.D

In anticipation of a talk I was asked to do at a national adoption conference I was looking through some of my client files. As a child psychologist, specializing in the effects of divorce or adoption on children, I always do a thorough intake interview with parents before meeting with the child. I wanted to review some of these interviews to remind myself of what issues would be important for me to address to a group of prospective adoptive parents.


As I read through 10 years worth of interviews, I was struck by one particular similarity. In fact, this theme became so pronounced that I started writing down the variations in which it appeared. These were comments made to me by parents of adopted children, and they included:


“Sometimes we just look at each other and ask what we got ourselves into”
“We knew this child would be different from us. But sometimes it seems we don’t know him at all”
“It’s narrowed down to keeping our marriage or this child, but not both”
“Every day I struggle with whether to give him back or not”
“I’ve lost control of my house and life to this child”
“Nothing I do or try seems like enough to help this child”
“We wonder how much longer we can stay committed to these children”


It is important to keep in mind that these comments were said in the context of a broader interview and certainly the parents expanded on the benefits of having an adopted child. Be it that they adopted because of infertility, helping out an extended family member, aiding abandoned children, or wanting to be a parent—even though single—most parents express that adopting their child is a life-changing event, with numerous rewards.

What we fail to sometimes take into account—and what many agencies don’t adequately prepare parents for—are the ways in which adopted children manifest with a variety of psychological characteristics that differ tremendously from other children. Sadly, many parents embark on the task of raising an adopted child ill prepared for understanding or coping with the behavioral manifestations of a child who often feels like a throwaway kid.

Today about 1 percent of children in the United States are adopted. According to one recent survey, 29 percent of adopted children come from abroad. Curiously, New Mexico has one of the highest per capita adoption rates in the country.

Adults wishing to adopt a child typically have to go through an intensive—sometimes grueling—series of procedures which may involve home studies, adoption education, addressing cultural and language concerns, psychological evaluations, and background checks with employers, neighbors and legal authorities. In addition, adoption can be an expensive prospect when one factors in fees from attorneys and adoption agencies, as well as the cost of air travel. Depending upon the family structure (e.g., couple, single, gay, younger, older, rural, suburban, etc.) and type of child desired (e.g., age, gender, availability to take a child with special needs, willingness to consider all countries, etc.), the time it takes to receive a child, once the process has started, can be anywhere from six months to two years.

It is not inevitable that every child who is adopted will present with behavior or emotional disturbance. Some children are simply more resilient than others are and they assimilate the reality of being adopted just fine. When we take a look at the variables that potentially affect the life of an adoptee, however, it is easy to see why raising an adopted child can end up involving much more than the parents ever anticipated or were prepared for.

Adopted children are over-represented in mental health and correctional facilities, compared to other groups. What I always find surprising is the lack of attention paid to the role adoption might have had in leading to the emotional or behavioral disturbance. As an example, Time magazine recently categorized the major risk factors associated with many of the children who have fired weapons at other kids. Whereas they listed the role divorce, abuse, and peer relations might have played in these children’s lives, they failed to acknowledge that at least two of the eight children profiled were adopted.

Child Development

A child’s development is affected by numerous factors. Increasingly, we are recognizing the role genetics plays in subsequent growth, learning, behavior and personality. Unfortunately, many adoptive parents have little, if any, information available to them about the adopted child’s gene pool. One of the things we do know about adopted children is that many were born to parents with histories of impulsive behavior. Either because of age, substance abuse, or psychiatric disturbance, these parents engaged in actions that produced a child they were unable to care for. This is one of the reasons why Attention-Deficit-type behaviors are so prevalent in adopted children.

The other reality affecting adopted children is that many had their lives disrupted in an untimely way or at an awkward phase of their life. Though some children are earmarked for adoption before they are born, the majority are adopted after already having lived with birth or foster parents. Children, be it consciously or not, carry memories of any abuse, abandonment, chaos or trauma they may have witnessed or experienced before being adopted.

Children are born helpless and dependent. It is not until a child is approximately two years of age that he or she moves toward independence. Infants need to move away from their parents on their own time-line. They need to be afforded the chance to test and explore the world away from their parents on their own, retreating back to the safety of mom or dad when things get scary. If this process is disrupted, by divorce or adoption, between two and four years of age, the child learns it is not safe to individuate (because people leave or abandon you if you do), and often fail to develop trust in others. These are the children who typically grow up feeling anxious, resentful and angry.

Another major developmental factor affecting adopted children is the role of cognition. Children under age seven are very concrete in their thinking. That is, they are not able to conceptualize cause-and-effect relationships until mid-childhood. Whereas many adopted children know at a very young age they are adopted, often telling others their ‘adoption story,’ it is not until the child is seven or eight that the personal meaning of this sets in. When cause-and-effect thinking sets in, adopted children start to feel, on a whole different level, that they were given away. This is one of the reasons why most adopted children don’t manifest with severe behavioral disturbance until second or third grade.

Finally, it is important to bear in mind that the inner world of the adopted child is one of ghosts. Whether they knew their birth family or not, adopted children inevitably carry real or imagined images of their mother, father, and siblings. In many respects, these ghosts dominate the adopted person’s life, asking for loyalty and recognition. The adopted child, however, may feel he has to keep the ghosts secret, lest the adoptive family feels betrayed by their presence. Whereas the adoptive family may hold the opinion that the birth parents relinquished their chance to raise the child—and should therefore be out of the picture forever—the child still holds on to whatever threads of connection he can maintain with these people.

Family Life

I tell every adopted parent who contacts me that they can’t approach raising their child in the way parents raising a birth child can. Rather, I tell them to conceptualize their role as ‘therapeutic parent,’ where every interaction—and its result—with their adopted child is deliberate and thoughtful. For example, when a parent punishes a birth child, the child rarely believes that the ultimate consequence will be parental abandonment. In the mind of the adopted child, however, parents leave. These children often believe that it is a matter of time before they are once again abandoned. If a parent fails to recognize this, relying instead on blind faith in their commitment to the child, they miss a vital life experience of the adopted child.

As anyone who has been dumped by a partner or spouse can tell you, being left by another person doesn’t feel good. In addition, it leaves us feeling out of control of our lives. Issues of control are therefore paramount for adopted children. Many feel they have no control in their lives and thus they do whatever they can to get it. I’ve seen some adopted children who are so convinced they will be abandoned again that they purposely and brutally antagonize their family members. Their belief system becomes, “Yes, I will be abandoned. But at least this time I’ll be in control, by causing it to happen.”

Adopted children are also incredibly hypervigilant. Their survival depends upon it. Therefore, they cue into subtleties and an enormous amount of effort goes into anticipating the actions of others. This is what makes it difficult for parents, particularly those who are preoccupied or coping with other stressors in their lives. Slowly and deliberately, their child knows all their weaknesses and vulnerabilities. When the child feels threatened or out of control, he or she knows how to ‘get’ mom or dad. Only later do the parents realize the ways in which the child controls many aspects of family life, often solely determining through manipulative behavior whether they will all have a good day or a horrible day.

Anger

Perhaps one of the major oversights adoptive parents make—one that agencies fail to adequately prepare parents for—is the role anger plays in the life of the adopted child. Many parents that I consult with mistakenly believe that a loving, stable home is enough for the adopted child; that a good home environment will make better all the losses or traumas from the past. To the adopted child, however, love isn’t enough. They have lost a great deal and they typically get little validation for this from those around them. Instead, many get the message they should stop wallowing and be grateful.

Those of us who weren’t adopted cannot fully grasp the meaning of being given away. As I work with adoptive parents on listening to their child, this issue becomes paramount. From the adult perspective, the adopted child was taken out of an unsafe environment and this should be seen as good. From the child’s point of view, however, something very valuable was taken away; their home, their identity, their family.

Children are quite adept at communicating their feelings. Strange as it is, adults consistently miss the messages. For the adopted child, anger is his way of communicating feelings of loss, grief, fear, and terror. Unfortunately, these messages get mis-interpreted and the child subsequently gets labeled as defiant. I would say that the majority of school age adopted children I see have been diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) and prescribed medication. This reflects a poor understanding of adoptive child behavior. These children often don’t have ADHD. They’re angry and fearful. It is difficult to pay attention, sit still, and get along with others when your world is one of unrecognized loss.

Conclusion

I am certainly not suggesting that adults stop adopting children. Nor am I insinuating that every adopted child will have behavioral or emotional disturbance. What I am pointing out, however, is that the needs and concerns of adopted children are unique. When we truly listen to the adopted child, we can better understand how he or she is attempting to make sense out of a life where they are asked to relinquish one identity and assume. Further, by being sensitive to the inner reality of the adopted child, we let them know we understand how confusing it can be to live in a world of ghosts, surrogate parents, and loss.










TEACHING CHILDREN NOT TO BE VICTIMS OF BULLIES
Published In: Tumbleweeds
Fall 2001

When school ended this past spring, there were daily reports in the media about school and teenage violence. Yet, with all the focus that has surrounded teenage gangs and gun violence, it may be easy to forget that the teenage years are not the only times that children face violent behavior. In fact, aggressive behavior and bullying are more common in elementary school than in junior and senior high, with studies suggesting that being a victim is the most common in second grade. Bullying behavior is at its peak in the first few months of the school year, as children vie for power among their peers.

Every child I see in my practice reports being bullied. This isn’t because I’m the bully doctor. Rather, children who are picked on tend to develop moderate to severe psychological symptoms. This can include depression, increased anger, school failure, refusing to go to school, physical ailments, or sleep problems. For children who already suffer from physical or mental handicap, their anxiety, rage, and sadness intensifies if they are being bullied.

Bullying can range from teasing, to stealing lunch money, to a group of students physically abusing a classmate. Bullies acquire power over their victims in many ways: by physical size and strength, by status within the peer group, by knowing the victim’s weaknesses, or making fun of the victim in front of others. With bullying, the bully’s dominance is established when the victim becomes distressed and fearful.

Bullies tend to come from families that have little warmth or affection. These families report trouble sharing their feelings, and most of the members do not see themselves as very close. Parents of bullies tend to use inconsistent discipline and little monitoring of where their children are throughout the day. Rigid physical punishment, conflict between siblings, and violence are also common in the families of bullies.
The traditional advice given to children who were being bullied was that they should either ignore it or else stand up to their tormentors. We know that this doesn’t always work. Bullying is usually done in secret, away from the eyes of adults. Boys usually bully boys, while girls bully in groups. Kids who are being bullied need adults to step in when bullying starts, because if they could solve it on their own, they would. We need to know that kids don’t learn any valuable lessons from being bullied, and that the best way to beat a bully is to avoid being a victim.

There are tips parents and teachers can offer children about bullying. First off, all children need to be taught strategies for dealing with any kind of harassment. Kids should learn to ignore comments and teasing, and that it is ok to shout at someone, Go away! Buzz off! Leave me alone! Don’t touch me! Bullies delight in their victims being scared, and they don’t want others to see them being embarrassed.

Children should be taught to stay out of bathrooms, hallways or streets where they might be alone with a bully. Instead, it is best if the child spends time with groups of other children. Children who are loners are at great risk of being bullied. Parents and teachers need to work toward finding ways of reducing the isolation these children experience.

A frank talk with kids about the meaning of true friendship is important. Bullying usually involves more than the bully and the victim. Though most students report that watching bullying makes them feel uncomfortable, they may support the act by passively watching or cheering. Children should know that friends don’t stand and watch someone hurt or bother one of their friends. Instead, they try to stop the bullying, escort their friend away from the situation, or get help from an adult.
Since most victims don’t tell their parents they are being bullied, it’s necessary for parents to take a proactive approach to this issue. Children can be reminded to report any situations, even mild one’s, where another child is saying or doing something mean. It can help to say, “Sometimes kids pick on other kids. Has this happened to you?” “The person picking on you is the problem, not you.” Parents should support the efforts the child took to handle the problem, paying attention to whether they need to get involved. While it may be enough to say, “You handled that great! I’ll bet he won’t bother you again,” some situations may require that the parent do more.

Parents should contact the school if their child is being bullied, but they shouldn’t expect school personnel to solve the problem on their own. It can be helpful to ask the teacher or principal if there is a school policy on bullying, adding that their child is being bothered. This creates an opportunity for the school official to share their perceptions of the child with the parent, and to report whether they have observed the child being bullied, or as is sometimes the case, doing things that provoke other children.
Parents might consider asking their child’s teacher if they engage the class in discussions on bullying behavior, since this can prevent problems before they occur. Bullying is less prevalent in schools where the staff openly acknowledges a no-bullying policy. Kids who are bullied also report greater trust in the teacher’s ability to intervene when the subject is talked about in class.

Most bullying is still considered a school discipline problem, not criminal behavior. While children rarely sue other children for threats, theft, or assault, it’s not a far-fetched idea. At that point, bullying will probably begin getting the kind of public attention now being given to sexual harassment in schools. In the meantime, parents should work to fight the problem head-on.





TALKING WITH CHILDREN ABOUT TRAUMA

Talking with Children About Traumatic Events

November 13, 2001

In the first few days following the attack on the World Trade Center, numerous media sources included information on talking with children about what had happened. I was very pleased to see this, since often, providing parents and teachers with tips on talking with children about trauma and crisis has come more slowly. While we hope and pray that nobody has to witness what we all did in September of this year, there will always be world, regional, or national events that children will look to us to help them understand.
Many parents have shared with me the confusion they feel about how to talk with children about things that happen they can barely comprehend themselves. While it is easier to tell a child that a flood, earthquake, or tornado is an act of God, it is much harder telling a child that violence or accidents are acts of man. Children naturally ask us why somebody would hurt another person, and quite frankly, there are not always answers for these questions.
As difficult as explaining trauma to a child can be, it is still a necessary part of our adult role. A key part of this, however, is communicating information to a child that does not add to further confusion or fear on her part. In order to achieve this goal, it can help to gear the content of the information we share with children toward their age and cognitive level.

Toddlers

Among the important life skills developed during toddlerhood is the ability to think symbolically. In the first few years of life, a child develops the capacity to think about their world, instead of just having to taste, touch, and hear it. Still, prior to age six, children are not able to perform the mental operations required for true logic and their understanding of events is quite literal. Psychologists call this concrete thinking, since the child mostly thinks about things she can see or hear. If I ask a four-year-old, “Do you have a brother?” he will reply, “Yes.” But if I ask, “Does your brother have a brother,” he will probably say “No.” Alternately, when a child this age hears, “Grandma died her hair,” she may develop a mental image of her grandmother with dead hair. During times of crisis or trauma, it is therefore important to provide children this age with simple facts they can readily comprehend. To this end, it helps to talk to children in terms they can relate to, such as, “People were hurt,” “People are scared,” “We don’t know who hurt them,” “The doctors are making sure they are okay,” “The kids are not with their family,” “Some animals were hurt and people are trying to find them,” or “They had to leave their house in order to be safe.”
Before age six, children exposed to trauma will not think about the event itself, but more typically will worry that it might happen again. Their fears become generalized, such that they grow increasingly concerned about fires, crashes, and accidents to come. Whereas older children and teenagers are more likely to feel anger following a trauma, younger children usually feel afraid, for themselves and for their parents.

Middle Childhood

The world of the school-age child no longer begins and ends with Mom and Dad. Instead, the child has meaningful, emotional relationships with people outside the family. Simultaneously, the child is developing the capacity for logical thought and sophisticated thinking. The most crucial of these is the capacity for cause-and-effect thinking, or the relationship between events. If I ask a five-year-old child why he should not run into the street, he will typically reply, “Because my mommy told me not to.” If I ask an eight-year-old the same question, he might reply, “Because I could get hurt or killed. I might have to go to the hospital.” The older child is able to recognize the relationship or interaction between events that the younger child cannot.
In light of this, children between ages eight and 10 can be told greater details about a traumatic event. While five-year-old children couldn’t fully grasp that a plane filled with people hit a building, and that many people were hurt or killed, older children could. Caution is still required with children this age, since they may grasp relationships, but not motives. Therefore, the following kinds of things can be helpful for children this age: “Some people who dislike this country flew a plane into a building, killing many people,” “Someone started a fire in the forest and many people had to leave their homes,” “A person was driving while drunk and their car crossed lanes and hit the other car,” “Someone shot a gun into a crowd of people and then left.”
At this age, children start to examine issues through a process of self-reflection. Thus, instead of just worrying about future trauma, school-age children will think through the sequence of events, asking themselves or others, “Why did it happen?” “Who are they?” “Where are they now?” Since this often happens during quiet reflection, it is important for parents to frequently ask their child, “What thoughts do you now have about what has happened?” Even though we may not always have answers for the kinds of questions a child may ask, it is still important that we try to find out the kinds of thoughts he has.

Adolescence

At about the age of 12 or 13, a new phase of cognitive development begins. Psychologists term this phase, “formal operations.” As opposed to “concrete operations” typical in younger children, “formal observations’ are highly abstract. Abstract thinking allows a teenager to focus on matters of morality, philosophy, and esoteric questions such as “What is the meaning of life?” For younger children, ‘right and wrong’ are defined in terms of behavior that does or does not get punished. In early adolescence, ‘right’ is whatever behavior wins approval or is in keeping with the social order.
At this stage, children are better able to recognize motives and consequences of action. While a school-age child may struggle with why someone would hurt another person, the adolescent can recognize that people can do hurtful things out of revenge or hatred. With respect to the World Trade Center bombings, most adolescents could recognize that there were social, political, and religious motives behind the terrorist attacks, something few school-age children could fully comprehend. Adolescents can also recognize that there are people who are so angry with this country that they would embark on a suicide mission, purposely trying to kill many people.

Children of all ages feel some degree of helplessness when faced with trauma or crisis. Yet, while younger children will primarily think in terms of how they can help make things better, adolescents tend to focus more on retaliation or retribution. Thus, topics of engaging in war, fighting back, or changing laws will be areas of focus for teenagers. Classroom discussions with older adolescents tend to yield more insight into options for managing terrorism, for example, than is true with younger children. It is therefore recommended that teachers in school-age classes focus more on practical, day-to-day matters with pre-adolescent children—such as ways of staying safe during a fire or disaster—than in trying to engage the class in discussions on the broader implications of a trauma or crisis.
School-age children and adolescents are likely to feel anger in response to trauma, especially if it is clear than man, not nature, created the horror in the first place. Philosophically, even for a child, it is almost impossible to remain permanently angry at God or the forces of nature. Especially if the child knows the perpetrator of the trauma or accident, anger becomes the dominant emotion. This anger needs to be validated for the child, while we reinforce non-violent options for managing anger.

Conclusion

In my experience, children often recognize that adults do not have adequate answers for some of the complex events that happen in our world. Still, they need reassurance that we know they are frightened or angry, and that our intention is to keep them and ourselves safe. It is comforting for children when we take the first step and acknowledge that certain events may be scary, confusing, or hurtful. I believe it is important that we not provide lengthy answers to children’s questions. Instead, permitting them the chance to express their feelings, while in the safety of our presence, can go a long way.
Finally, children and adults inevitably feel helpless when there is a trauma or crisis. Children, especially, want to feel they can make meaningful contributions when bad things happen. I therefore encourage parents to think of ways their child can give to others following a crisis. This can include donating a small amount of money to a relief organization, pet food to the animal shelter, clothing to the aid agencies, or even writing a note of support to persons who might have been affected.

Christopher J. Alexander, Ph.D. is a child psychologist in Santa Fe.






REFLECTIONS ON LEAVING THE PENITENTIARY: A PSYCHOLOGIST TAKES STOCK
By training, I am both a child and forensic psychologist. The two specialties, when combined, have had me doing evaluations for abuse and neglect, custody determinations, divorce mediation, trauma assessment, and lots of play therapy. The combination also means that I have spent many hours in law offices, judges chambers, and courts of law, always advocating for the best interest of the child. This is the work I devoted the majority of my career to prior to moving to New Mexico in l995.

In light of my background, it is curious that the job I took shortly after arriving in New Mexico wasn't the role of private practitioner, of which I was accustomed. Rather, I was hired on as the supervising psychologist at the Penitentiary of New Mexico at Santa Fe. My duties, at the North or maximum security unit, included supervising a staff of five mental health workers, doing personality and neuropsychological evaluations on the male inmate population, and facilitating training for prison mental health workers throughout the state on understanding the criminal mind. A significant portion of my time has also been spent negotiating my way through the Duran Consent Decree, the mixed state of legal affairs the Penitentiary has found itself confronting for over fifteen years.

As a child psychologist, I dealt primarily with victims. The children I saw were forced to deal with the brutal realities of divorce, neglect, abuse, violence, and overall states of chaos. By coming to the Penitentiary, my role changed. Instead of doing what I could to find ways of protecting our more vulnerable members of society from victimization, I found myself working with the perpetrators of these crimes. Particularly at the North Unit, the perpetrators I work with are what we termed, 'mad and bad.' That is, many are neurologically impaired from multiple head trauma and life-long substance abuse, most have concurrent mood, learning or mental disorders, and all suffer from chronic and severe personality dysfunction.

It took some getting used to, but one aspect of working as a psychologist in prison is that you can't create a mental hierarchy based on the crime committed. That is, I found myself treating equally the inmate who raped and killed a child, and the one who sold drugs to the under-cover officer. When you deal with an inmate population on a daily basis, you see that they really are people, with all the positive and negative attributes common to all of us. With this perspective, it becomes possible to relate to them, not as the horrific beasts many in society choose to believe they are, but instead as men with families, dreams and feelings of their own.

It is often said that the role of prison isn't rehabilitation, but rather containment. Thus, I never had any fantasies of transforming the lives of my clients based on my skillful administration and interpretation of psychological tests, careful supervision of the mental health staff, or understanding of the criminal mind. But I guess I did hope that I would be able to find some way of affirming my professional integrity and identity, and to feel I was doing something that could fall under the category of helping. This, however, was difficult to achieve. Guiding someone toward positive mental health is often about encouraging them to explore the options available to them. When you're incarcerated, your options are few.

Life in Prison

The world of prison is a harsh and brutal one. The madness that gets played out---by both inmates and the staff---is incomprehensible for most people. In fact, when friends curiously inquire what it is like working in a prison, I use every tactic of deflection available to me as a psychologist to change the subject. Often, this is less about my not wanting to talk about it, and more about my belief that most people would have a difficult time stomaching or believing what I might have to share.

A good example of this is how the sociopathic behavior and patterns of criminals don't stop once they are imprisoned. To the contrary, prison is the best environment many of these men have ever had in their lives. The predictability and relative constancy of the prison environment permits the antisocial tendencies of many inmates to grow and thrive. Thus, many of the inmates know which staff members can be bought, how to secure a steady supply of drugs, and how to manipulate and maneuver their way through one of the most controversial and complex systems in our state.

As a learning experience, however, there are few better places than prison. One thing working in a prison has taught me is that standard psychological training is simply incapable of adequately capturing the full extent of mental function of the human mind. Since I am accustomed to being cross-examined on the features, causes, and treatments for various mental disorders, I know the classification systems forward and backward. Yet, when you spend time with true sociopaths, narcissists, and persons with bipolar disorder, the failure of our current classification methods to identify the complexity of mental functioning becomes obvious. Prison work, though, really does help one better understand the likes of Charles Manson, Ted Bundy, Andrew Cunanan, as well as New Mexico's high profile criminals.

The extent of head trauma that most male inmates have endured is also notable. Typical causes of these injuries include accidents, gun-shot wounds, and beatings. Severe head trauma in anyone is directly responsible for everything from personality change to impaired impulse control. When you factor in long-standing patterns of inhalant and other substance abuse, the brain of the typical maximum security inmate is hardly capable of helping these persons negotiate the complexities of a social world.

Perhaps more than anything, however, working in a prison has reaffirmed for me that it is best that I work, not as a prison psychologist, but as a child psychologist. It is not that prison work exceeds my abilities or interests. Rather, prison work reminds me of a thought I often had when I was working with chronically abused children: "I wish I'd had them sooner." In other words, it really is true that in order to effectively intervene with someone who is on the path toward gang involvement, criminal acts, or other antisocial behaviors, we have to treat or help them while they are young. I'm not yet willing to write off the incarcerated adults in our nation's prisons. But reversing what for them has become learned and adaptive ways of surviving and functioning in life is an insurmountable challenge.

Working with the incarcerated has made it difficult for me to separate out their criminal acts from their broader life picture. For example, when I read of what these inmates did to other humans, it astounds me. The extent of victimization and brutality that many have inflicted on others in society is best left unsaid. But what is equally harsh is the madness many of them had to endure in their own lives. This certainly doesn't---and shouldn't---excuse what they have done to others, but I do believe we need to maintain some perspective on this issue.

In my work with children, I have had the unfortunate task of reading through medical files and looking at police photos of the worse forms of neglect and abuse. None of this, however, prepared me for hearing what the childhood was like for many of the inmates I evaluated; four year olds being given illicit drugs by their caregivers, six year olds being taken on store robberies with their fathers, mothers engaging their young boys sexually from a very early age, boys being forced to participate in the rape and torture of other children, boys who were tied to outdoor posts in the winter while being severely physically abused.

It is with these experiences and observations in mind that I returned to the private sector. But instead of feeling that I somehow made a wrong turn in my career, I believe I needed the experience of working in the Penitentiary to clarify my understanding of why I do the work that I do. This experience has not only reaffirmed my professional commitment to advocating for the best interests of the child, but it has made me personally realize that each of us has to do whatever it is we can to make life better for all children in our state. I have also come to realize that every one of us really can affect the outcome of children's lives in positive ways, be it that we are child care professionals or just caring members of the community. As several inmates have told me, "one caring adult in my life would have made all the difference."




DEVELOPMENTAL ATTACHMENT AND GAY AND LESBIAN ADOPTIONS
Published in: Journal of Gay and Lesbian Social Services

Several months ago a gay man who was in the process of adopting a five-year-old boy contacted me. It had been recommended to him that he speak with me about ways to facilitate the bond between he and his child. During our interview, I emphasized to this man the role of attachment in early childhood, and I encouraged that he give his boy lots of physical touch and eye contact after he arrives. I also pointed out that his new son-who had been in foster care for the past three years-will likely be very fearful of living in a new home and that ways of making the boy feel secure will need to be considered. I offered that he consider letting the boy sleep with him, at least initially, as a way of softening the child's fears.
At our next appointment-which we scheduled for a few days after his adopted son arrived-the man told me he awoke the first night to find the boy standing at his bedside. The boy acknowledged being afraid, to which my client suggested that the boy get into bed with him. My client then said the boy stood there teary-eyed, obviously wanting comfort. Yet, he looked at his new father and said, "No. I was told you would hurt my butt," a fear planted in his vulnerable mind by his foster mother. Clearly, my client was stunned, as every stereotype and fear of being a gay father began to overwhelm him.
This example is a bit dramatic but it speaks to one of the challenges for gays and lesbians who foster or adopt young children. That is, how to interact with their children in loving and nurturing ways without falling prey to the messages many have internalized that gays and lesbians exploit children in sexual ways. It is also just one example of how adoption by gays and lesbians brings up other behaviors that are unique to these families. When clinicians and researchers maintain adequate perspectives on these kinds of issues, unsubstantiated or unwarranted interventions or conclusions can be avoided.

Gay and Lesbian Adoptions

It is estimated that there are 500,000 children in foster care nationally, and 100,000 need to be adopted. In recent years, however, there were qualified parents available for only 20,000 of these children (Petit & Curtis, 1997). With increasing numbers of gay men and lesbians choosing to raise children, many are looking at the option of adoption. This trend has been met with both hope and reluctance by the various persons and agencies responsible for placing adopted children. For example, gay men and lesbians have typically been subject to more rigorous background checks (Ricketts, 1991) and increasingly, some states (e.g., Florida, Utah, and Mississippi) are banning gay adoptions (Mueller, 2000). Yet, social workers, responsible for the daunting task of placing children, are often grateful to have any loving home with which to offer a child.
The American Psychological Association (1995), in a report reviewing the research, observed that not a single study has found children of gay and lesbian parents to be disadvantaged in any significant respect relative to children of heterosexual parents. The report concluded that home environments provided by gay and lesbian parents are as likely as those provided by heterosexual parents to enable and support children's psychological growth. This does not mean that gay and lesbian families do not continue to face unique hurdles. For example, regardless of whether they have children or not gays and lesbians do not have the same legal protection as heterosexuals (Sullivan and Baques, 1999).
It is important that we maintain awareness that circumstances or life events common to adoptive families will inevitably arise in gay and lesbian families. Adoptees certainly present their own challenges and opportunities for families and we should avoid placing too much emphasis on the sexual orientation of the parents when what is occurring is a commonplace, adoptive family experience. This is particularly true with regard to developmental attachment.

Attachment

As is true for all adoptive parents, gays and lesbians must be sensitive to bonding and attachment concerns of their child. In essence, attachment behavior is any behavior designed to get children into a close, protective relationship with their attachment figures whenever they experience anxiety (Howe, Brandon, Hinings, and Schofield, 1999). For most children, their primary attachment figure is their mother or main care provider, though it is recognized that children can have attachment relationships with a limited number of other people (e.g., fathers, grandparents, and older siblings). Children who experience disruptions between themselves and their birth mother, as is the case in adoption, are vulnerable to many psychological difficulties, the most noteworthy being attachment disorder.
Attachment disorder is defined as the condition in which individuals have difficulty forming lasting relationships (Thomas, 1997). They often show nearly a complete lack of ability to be genuinely affectionate with others, and many fail to develop a conscience and do not trust. Levy and Orlans (2000) note that neglectful, abusive, and nonresponsive caregivers produce out-of-control, angry, depressed, and hopeless children by two to three years of age. These children are often misdiagnosed with Attention-Deficit/Hyperactivity Disorder, with many developing severe problems, including aggression.
Whereas we can't reverse the neglectful mothering relationship that results in her child being placed for adoption, there are steps adoptive parents can take to minimize the impact on a child of disrupted attachment. This is where frequent eye contact, smiling, and touch become crucial. Touch for the human baby serves both physical and emotional functions, and human babies actually die from the lack of touch.

Psychiatric Disorders

Although adopted children and adolescents comprise only a small minority of the population in the United States, they have been reported to account for a significant number of young patients treated in psychiatric settings. Ingersoll (1997) notes that adopted children are three to six times more likely than non-adopted children to be referred for psychiatric treatment. Ingersoll adds that this prevalence rate may reflect the fact that adoptive parents tend to be better educated and more affluent than parents in the general population and therefore more alert to knowing when psychological services may be called for.
There are certainly a variety of factors that can predispose an adopted child to psychological disturbance. For example, many adopted children are born to teenage mothers, who often do not receive adequate prenatal care. Teenage pregnancies are also associated with low birth-weight, which in turn is associated with behavioral and emotional problems in childhood. Substance abuse during pregnancy places children at high risk for emotional and behavioral problems.

Caution Warranted

My concern is that teachers, neighbors, and/or researchers who witness attachment or psychological disturbance in adopted children of gays or lesbians will falsely conclude that it is the sexual orientation of the parents-not a biopsychological process-that is creating the difficulties. Gay and lesbian parents with whom I have worked are particularly sensitive at having their child rearing skills judged in negative ways, solely based on their sexual orientation. Most have openly questioned how much of their child's misbehavior is a manifestation of growing up in a gay or lesbian family, versus other causes.
Ultimately, we need to trust that two decades of research on gay and lesbian families is correct. That is, that children raised in these households do indeed have to contend with unique circumstances, but that social and emotional development proceeds in a normal manner. There is the risk, however, of lending too much credence to sexual orientation when children in these families experience problems. As research and clinical work in this area increases, it is imperative that a balanced perspective be maintained, and that conclusions or interventions not be applied that serve to judge or categorize.






GAY YOUTH: MORE VISIBLE, BUT FEWER PROBLEMS?
Published In: Journal of Gay and Lesbian Social Services


Just over a year ago, I received a phone call from a local representative of PFLAG (Parents and Friends of Lesbians and Gays). A social worker in town had asked this woman whether she was aware of a foster home for gay children. Apparently, the parents of a 10-year-old boy suspected he is gay and wanted him out of the home. The caller from PFLAG was shocked when I informed her that I was not aware of a home or facility for gay 10-year-old boys. Even after I reminded her that most pre-adolescent boys do not self-identify as gay-and therefore how could we find the right population of children to enter a foster placement for sexual minority youth-she could not believe what I was telling her.
Since that time, I have been struck by the way parents have approached the issue of their child's presumed homosexuality with me in therapy. For example, a divorced mother of a 12-year-old boy told me, "He's definitely gay. I'm just not sure he knows it. But I think it would be a good topic for the two of you to discuss." Another mother, speaking to me about her eight-year-old boy, said, "He's probably gay. Kids tease him about it all the time. He likes kissing other boys. I tell him it's ok to like boys, but that he can't express his affection for them until he is older." And finally, I will never forget the mother who shouted to her 10-year-old adopted boy during one of our sessions, "I don't care if you choose to live with me forever. I don't care if you get married. I don't even care if you are gay! I just want you to be happy."
I don't imagine that these experiences are that different from many other clinicians. In fact, I suspect that the issue of children's sexuality, in general, is increasingly finding its way into many consulting rooms. A woman I supervise, for example, mentioned to me that she has five different adolescent girls who all admit to kissing other girls on a regular basis. Another intern of mine recently brought to supervision a case of a 15-year-old girl who primarily spends her time with gay and lesbian teenagers. Clearly, the sexuality of children is pronounced in ways it wasn't ten or more years ago. This is not to say that children have not had sexual feelings, or even that children have not, historically, had non-abusive, same-sex sexual experiences. But it appears there is a growing consciousness of sexuality, sexual expression, and recognition of sexual orientation in children. Given that five to 10 percent of youth will discover they are gay or lesbian before age 17 (The Committee on Adolescence, 1993), this trend is likely to continue.
It can be argued that there are many positive aspects of society recognizing sexuality in our youth. But mental health professionals and others in the broader society should not fall prey to the false belief that the lives of young gay and lesbian children are easier than it was for many of us when we were growing up. My eight-year-old client who kisses boys is clearly trying to sort out many gender-related issues. But given that he lives in a town of less than 20,000 people, rumor of his trying on his sister's clothes or lip-singing to Janet Jackson CDs could get him killed. My 12-year-old client whose mother insists he is gay may have the love and support of his primary parental figure. But his older brother doesn't like him, nor will he intervene when kids at school make fun of his sibling. Why? Because his brother is, as he told me, "a freak."
This and other professional journals have included several articles acknowledging the increased suicide risk for gay and lesbian youth. If there is one consistent finding in research on gay and lesbian youth, it is the role of suicidal thought, intent and action. This was most clearly documented in a publication of the US Department of Health and Human Services, titled "Report of the Secretary's Task Force on Youth Suicide (1989). Findings published in this Survey documented that approximately 30 percent of gay and bisexual males have attempted suicide at least once. A subsequent study by Savin-

Williams (1994) found that 41 percent of teenage girls and 34 percent of teenage males had actually attempted suicide due to sexual orientation-related concerns.
In a more recent study (Garofalo, et. Al., 1998), researchers at Children's Hospital/Harvard Medical School, examined data on ninth to 12 graders who participated in the Centers for Disease Control and Prevention's 1995 Youth Risk Behavior Survey. Of the more than 4,100 surveyed students, 104 claimed to be gay, lesbian or bisexual. These researchers also found that gay, lesbian, and bisexual teens were more than three times as likely to have attempted suicide in the past year; nearly five times as likely to have been absent from school because of a fear about safety; and more than four times as likely to have been threatened with a weapon at school. In an analysis of whether they took risks at an earlier age, the researchers discovered that teens who used cocaine, alcohol and marijuana and had sexual intercourse before they were 13 were more likely to be homosexual or bisexual.
The results of the Centers for Disease Control Survey were viewed as so unsettling by numerous medical, mental health, and education organizations that a committee was formed to address issues pertaining to gay and lesbian youth. Out of this committee came the pamphlet, Just the Facts about Sexual Orientation and Youth. This pamphlet, written by members of groups such as the American Academy of Pediatrics, the American Counseling Association, the National Education Association, the Interfaith Alliance Foundation, and the American Psychological Association, will be released in early 2000. The pamphlet will be mailed to superintendents of every school district in the United States. It will be to the discretion of each superintendent whether to distribute the pamphlet throughout his or her school district. Anti-homosexual groups such as the Family Research Council are rigorously opposing this most astounding effort.
There is another growing trend, one that I personally believe will go a long way toward helping parents of gay and lesbian children. I am referring to the fact that issues of sexual orientation are slowly, yet increasingly being addressed in mainstream parenting publications. Granted, most of the popular-press parent magazines are not tackling this issue. And when I tried to do an on-line search on gay youth at
several parenting websites, I came up with nothing. But when we look back on one of the major news topics in 1999, it was the rise in popularity of books on boys (Though very little is being written in parenting publications on lesbians, my hope is that this omission will not be long-standing). In a 12-month period, no less than five books on raising boys were published. I believe this phenomenon alone made front-page coverage on one or more weekly news magazines.
The most popular of these books, Real Boys (1999) includes a full chapter, titled, "Being Different: Being Gay." In it, author William Pollack writes:
Yet during adolescence when most young people begin to question their sexual identity, many homosexual boys do not feel comfortable speaking to either their peers or their parents about their fears and confusions. At this age boys feel that they must keep their feelings secret, and often sense there is nobody willing to talk to them in a safe and confidential way about what they are experiencing. (p. 208)

Writing mainly to parents of school age boys, Dr. Pollack adds, "I have found that this homophobia-not homosexuality itself-is what makes the lives of gay people so difficult".
Author Marianne Neifert, in her 1999 book on parenting, addresses the fact that many parents reject their child when they find out he or she is gay or lesbian. She writes:
Have you ever thought about what conditions would make you stop loving your child "unconditionally?" I certainly wouldn't choose for my own child to be gay. Neither would I want my child to be promiscuous. But more important, I would not be willing to withdraw my love on the condition of my child's sexuality, any more than I would withdraw it on the basis of another personal attribute. (p. 306)

In short, these authors-many of whom are psychologists or doctors-are taking the research we have published in our professional journals and translating it into a readable and accessible format for the lay public. This reinforces the importance of doing research in these crucial areas of social sciences, and it reminds us that people are paying attention, particularly when study after study substantiates the often brutal truth of how life is for many sexual minorities, particular our younger members.








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