DEBBIE B. RILEY AND ELLEN C. SINGERMANY CHILDREN ADOPTED TRANSRACIALLY AND from other countries have experienced trauma from abuse, neglect, abandonment, and institutionalization, which result in emotional, cognitive, social, and behavioral challenges, leading adoptive parents to seek professional help. Adoptive families who seek help to address mental health issues within their families often find it difficult to find adoption-competent mental health professionals who can address their unique needs. This chapter will highlight the critical need for knowledgeable professionals and explain what makes a professional “adoption competent,” with an emphasis on the effects of preadoptive traumatic experiences. Through case examples and presentation of effective therapies, we will explore how professionals can assist families in addressing children’s adjustment in families who are of a different racial and ethnic background, adapt to new home and country environments different from their country of origin, promote attachment, help heal from trauma, and cope with feelings of loss and grief. Strategies for finding adoption-competent practitioners are provided.
The need for adoption-competent mental health services has been well documented (Brodzinsky, 2013; Freundlich, 2006; Lenerz, Gibbs, & Barth, 2006; Smith, 2014). Many children who have been adopted through intercountry adoptions come from compromised beginnings. Research shows that children with traumatic experiences of abuse, neglect, abandonment, and challenging behaviors are at high risk of presenting with adjustment problems during their development. As a result of these mitigating factors, adoptive families are three to four times more likely to engage their children in counseling and five to seven more times likely to send their child to a residential treatment facility (Howard, et al., 2004; Landers, Forsythe, & Nickman, 1996; Price & Coen, 2012; Vandivere, et al., 2009). All too frequently, adoptive parents identify the complexities of compromised beginnings in intercountry adoption as the primary contributors to family stressors. Issues related to ethnic and racial differences in adoptive families often are identified as well, although it is also true that parents may be unaware of how this factors into the challenges they are experiencing. Access to adoption-competent mental health services is a critical factor in promoting positive outcomes for adoptive families.
Adoptive parents consistently report that their greatest post adoption support need is mental health services provided by someone who understands adoption (Atkinson & Gonet, 2007; Brodzinsky, 2013; Smith, 2014). Some families reported seeking therapy from as many as ten different therapists before finding one who understood adoption issues, if they found such a therapist at all (Casey Center for Effective Child Welfare Practice, 2003). So it is not surprising that studies indicate that most mental health professionals lack the training to meet the diverse and complex clinical needs of adoptive families (McDaniel & Jennings, 1997; Sass & Henderson, 2002). In a study investigating the level of preparation psychologists have related to adoption and the need for further education, out of 210 participants, only 51 percent rated themselves as “Somewhat prepared” with the second largest group (23 percent) rating themselves as “not very prepared.” Ninety percent reported they needed more education in adoption. Only sixty-seven participants reported taking courses that dealt with adoption as part of their formal education, and they averaged only 1.3 courses during their undergraduate education, and 1.5 during graduate school (Sass & Henderson, 2000).
Many intercountry adoptive families face mental health crises with their children that place the adoption itself at risk. Issues arise that in some cases can undermine the safety of the child or other members of the family. Factors such as prenatal complications, including poor prenatal care and prenatal exposure to toxic substances (Barth & Brooks, 2000), early childhood breaks in attachment, maltreatment and trauma related to emotional abuse, physical and sexual abuse, exposure to violent acts, unresolved grief and loss, nutritional and emotional deprivation, and the impact of institutionalization (including multiple caregivers), along with genetic vulnerabilities, contribute to the risk (Barth & Brooks, 2000; Briere, Kaltman, & Green, 2008). Studies of children adopted from orphanages in China, Russia, and Romania found that the most significant factor affecting future problems was the length of time in institutionalized care (Meese, 2005). It is the profound impact of these early life experiences as well as ethnic and racial differences that create challenges for the children and their families, creating the need for effective clinical intervention and other postadoption supports.
“Every time I left my son’s therapist’s office I felt like a failure. He is so angry at me for being white.”
Coleen, adoptive mom, age 43
“I was sitting in the hospital after trying to kill myself and the social worker lady told me I should be “happy” that I was adopted as my parents had gotten me out of that horrible orphanage.”
Andrew, adoptee, age 16
Many of the issues related to children’s racial identity and socialization emerge most fully long after the adoption is finalized. As transracially adopted children enter adolescence, these issues are likely to have particular salience (Smith et al., 2008). Feigelman (2000) found that appearance discomfort was linked with higher levels of adjustment difficulties in transracially adopted young adults. Studies that include qualitative methods find that many transracial adoptees report a struggle to fit in with peers, the community in general, and, sometimes, their own families (Freundlich & Lieberthal, 2000; John, 2005; Simon & Alstein, 2002; Trenka, Oparah, & Shin, 2006).
Without access to adoption-competent mental health services, adoptions can and do fail. Children may enter state child welfare agencies through “forced relinquishments” or place their children in residential treatment facilities or wilderness programs, choices parents make when they lack access to the appropriate resources. Most alarming were the recent media reports regarding “rehoming” (Twohey, 2013). The report revealed desperate adoptive parents, feeling unable to parent their children connecting with strangers via the Internet, handing over “custody” to strangers, often placing their children in abusive, dangerous situations. In this horrific practice, the investigation found that there were more than 5,029 posts spanning a 5-year period advertising adopted children available for rehoming. According to the investigation, children ranged from 6 to 14 years of age and all were adopted abroad (Twohey, 2013).
In addition, one cannot forget the Tennessee mother, who in May 2012, sent her 7-year-old adopted son on a plane alone back to Russia, claiming she could not handle his severe behavioral problems. She sent the boy alone with a note that partially read; “I am sorry to say that for the safety of my family, friends, and myself, I no longer wish to parent this child” (CBS/Associated Press, 2012). As horrific and surprising as this is, it is reflective of the fact that too often, families are unprepared for the parental task of parenting children who come from compromised beginnings or of a different culture, ethnicity, or race. Sadly, the absence of adequate resources to assist them leaves families floating adrift with no lifeline.
A RESPONSE TO THE NEED: SUPPORTING ADOPTIVE FAMILIES
Recognizing the need for a responsive system of care, the Center for Adoption Support and Education (C.A.S.E.) was created in 1998, to provide pre- and postadoption counseling and educational services to foster and adoptive families, as well as training for educators, child welfare staff, and mental health providers in Maryland, Northern Virginia, and Washington, DC. C.A.S.E. has become a national resource for foster and adoptive families and for professionals through its training programs, publications, and distance consultations. Cited in the Donaldson Institute October 2014 research publication, Keeping the Promise: The Case for Adoption Support and Preservation, C.A.S.E was identified as a promising practice providing leadership and innovative programming for postadoption services.
C.A.S.E. has more than 17 years of experience in service delivery to more than 5,500 foster and adopted children, adolescents, and their families; adult adoptees and their families; and expectant and birth parents and their families as well as to more than 20,000 professionals. Their clinical interventions have resulted in successful transitions from foster care or institutionalization to permanency; healing of early trauma, loss, and grief; stabilization of families in crisis; the promotion of secure attachments; an increase in self-regulatory behaviors in children; improvement in children’s adjustment; higher functioning in school and community; and, most important, adoption preservation.
To achieve its mission, C.A.S.E integrates evidence-based best practices and promising practices along with innovation to provide premier resources and training that advance permanency for children and the healthy growth and development of families.
Building the Framework
The C.A.S.E. promising practices model of comprehensive family-focused treatment addresses the complex needs of adopted children and their families. The conceptual framework was deeply embedded in the guiding principles of the work of the National Consortium for Post Legal Adoption Services: Adoption Support and Education (Arneaud et al., 1996). The model further predicates that families should have access to an array of services that range from advocacy to psychosocial services. This framework was further solidified by the integration of several theoretical models, including family systems theory, attachment, grief and mourning, and trauma-informed treatment.
Family systems theory embodies the view of families as dynamic, changing, interacting compilations of emotional and behavioral systems and subsystems. Family systems theory is key in the treatment of adoptive families. Many of the challenges facing international adoptive families are seen as connected to developmental processes or normative crises in the development of the adoptive family (Falicov, 1988; Pavao, 1992). Recognizing the complexities of relationships that bind the ties in adoption, early work by Reitz and Watson suggested that problems experienced by a client could be treated within the context of the extended family systems, birth and adoptive, created through adoption: “Although the family system for treatment remains the primary family system of the client, it is essential to the provision of effective service that a professional work within the conceptual context of the many systems involved” (1992, p. 12).
Attachment is the term for the social, psychological, and affective relationship between a child and one or more specific persons with whom the child interacts regularly; it is a mutual and reciprocal emotional connection between a child and a caregiver (Hirschi, 1969; Wilson & Hernstein, 1985). On the basis of early life experiences with their caregivers, children develop a cognitive model of themselves, their caregivers, and the world around them (Bowlby, 1969, 1973, 1988). This cognitive model is transferred to other relationships. To develop secure attachments and confidence about relationships, children must receive sensitive, nurturing care (Carlson, Cicchetti, Barnett, & Braunwald, 1989.) Attachment theory emphasizes the role of a child’s birth parents in shaping the child’s ability to form emotional bonds (Bowlby, 1988; Fahlberg, 1979). For adopted children, attachment theory suggests that the preplacement history of the adopted child can deeply influence the quality of later adoptive family relationships (McRoy et. al., 1988).
Grief is the reaction to loss and mourning is the expression of grief that is integral to the grieving process. Loss in adoption is explored later on in the chapter. Psychologists and researchers have outlined various models or phases of grief. In 1969, Elisabeth Kubler-Ross identified five linear stages of grief with which most people are now familiar: denial, anger, bargaining, depression, and acceptance (Kubler-Ross, 2014).
Kubler-Ross originally developed this model to illustrate the process of grief associated with death, but she eventually adapted the model to account for any type of grief. Kubler-Ross noted that everyone experiences at least two of the five stages of grief, and she acknowledged that some people may revisit certain stages over many years or throughout life (Kubler-Ross & Kessler, 2014). The theory of “ambiguous loss” developed by Pauline Boss has significant relevance to treatment of internationally placed children and will be discussed later on in the chapter (Boss, 2000).
Trauma-informed treatment refers to treatment that incorporates (1) an appreciation for the high prevalence of traumatic experiences in individuals who receive mental health services; (2) a thorough understanding of the profound neurological, biological, psychological, and social effects of trauma and violence on the individual; and (3) clinical skills and interventions that address the effects of trauma (Jennings, 2004). Models of trauma-informed treatment are discussed later in the chapter.
DEFINING ADOPTION COMPETENCY
Research continues on the specific features of clinical practices that distinguish them as “adoption competent.” These achievements are components of a multiyear initiative to which C.A.S.E. has provided leadership since 2007, the Training and National Certification for Adoption Competent Mental Health Practitioners. The long-term goals of the initiative are to expand the access of prospective adoptive parents, adopted individuals, birth families, adoptive families, and kinship families to adoption-competent mental health professionals.
DEFINITION: AN ADOPTION-COMPETENT MENTAL HEALTH PROFESSIONAL
This definition was developed by the Center for Adoption Support and Education in collaboration with a National Advisory Board, which is composed of leading adoption practitioners, researchers, advocates and policy makers, and, importantly, adoptive parents.
An adoption-competent mental health professional has the following skills:
The requisite professional education and professional licensure; A family-based, strengths-based, and evidence-based approach to working with adoptive families and birth families;
A developmental and systemic approach to understanding and working with adoptive and birth families;
Knowledge, clinical skills, and experience in treating individuals with a history of abuse, neglect, or trauma; and
Knowledge, skills, and experience in working with adoptive families and birth families.
An adoption-competent mental health professional understands the nature of adoption as a form of family formation and the different types of adoption; the clinical issues that are associated with separation and loss and attachment; the common developmental challenges in the experience of adoption; and the characteristics and skills that make adoptive families successful.
An adoption-competent mental health professional is culturally competent with respect to the racial and cultural heritage of children and families.
An adoption-competent mental health professional is skilled in using a range of therapies to effectively engage birth, kinship, and adoptive families toward the mutual goal of helping individuals to heal, empowering parents to assume parental entitlement and authority, and assisting adoptive families to strengthen or develop and practice parenting skills that support healthy family relationships.
An adoption-competent mental health professional is skilled in advocating with other service systems on behalf of birth and adoptive families (C.A.S.E., 2007).
Although the terms “adoption competent” and “adoption sensitive” frequently have been used, there was no standardized, well-accepted definitions for these terms. To address the need for a comprehensive definition, in 2007, C.A.S.E. convened a group of nationally recognized experts, including parents, who identified the specific knowledge, skills, and values competencies that mental health practitioners need and helped to develop a definition of an adoption-competent mental health professional using an expert-consensus process.
Findings reported in this chapter are from a survey of adoptive parents and other members of the adoption kinship network conducted in early 2011. The central purpose of the survey was to determine whether members of the adoption kinship network agree with the definition developed by experts and to examine more closely their views on the specific elements of the expert-developed definition. Additional questions were asked about their own experiences with mental health services and the availability of various types of assistance with accessing mental health services.
Respondents
A total of 400 people from thirty-eight states and five countries outside the United States responded to the survey (Atkinson et al., 2013). Eighty-seven percent were adoptive parents, 7.6 percent were adopted persons, and 9.1 percent were members of an adoptive family.
More than 81 percent of respondents reported they had seen one or more mental health professionals or had been involved with the treatment of another family member. Eighty-two percent of adoptive parents and almost 66 percent of adopted persons reported having seen one or more mental health professionals.
Experience with Mental Health Professionals
Of the 319 respondents who reported they had seen a mental health professional, 24.1 percent reported that the mental health professionals were adoption competent, 26.3 percent reported the mental health professionals were not adoption competent, and 49.5 percent reported that some were and some were not adoption competent.
Nearly one-quarter of respondents found that therapists had a lack of knowledge about attachment, trauma, loss, adoption language, or any real understanding of adoption. Several parents reported that therapists did not understand that the underlying issues were adoption related. Findings from this survey are consistent with those reported in the Evan B. Donaldson Adoption Institute’s Keeping the Promise (2010).
Importance of Adoption-Competency Training
When asked how important it is for a therapist to have specialized training or a certificate to provide services to adoptive families, almost 80 percent rated training as “very important” and about 17 percent rated it “moderately important.” Only 2.5 percent rated the training “a little important” and less than 1 percent reported it not important.
THE TAC MODEL AND OTHER POSTADOPTION TRAINING PROGRAMS
Over the past two decades, various levels of postgraduate adoption-competency training programs have been developed across the country. Some programs are geared toward child welfare staff, and others combine both mental health professionals and child welfare professionals. In A Need to Know: Enhancing Adoption Competence Among Mental Health Professionals (Brodzinsky, 2013), there were at least sixteen programs around the country providing training in the psychology of adoption and foster care. In Brodzinsky’s analysis of the current program, he states “although there is a considerable overlap across programs in many of the core adoption issues covered in their curricula, differences in course content do exist and there is considerable variability in length—from 45 to 96 training hours. In addition, some programs have a strong clinical focus, whereas others do not” (Brodzinsky, 2013, p. 34). To view a complete listing of current adoption-competent training programs and their descriptions, please see the appendix in A Need to Know (Brodzinsky, 2013).
The following discussion will focus on the model created by C.A.S.E to deliver a manualized, rigorously evaluated protocol that can be replicated effectively with high fidelity to content delivery throughout the United States.
Creating a definition of an adoption-competent mental health professional was not only an invaluable contribution to the body of knowledge with regard to adoption competent mental health practice but also has served as the foundation for the development of C.A.S.E.’s TAC (Training in Adoption Competency). The TAC curriculum was developed and pilot-tested in 2009 at the University of Maryland School of Social Work. It currently is being implemented in fourteen sites across the United States (Connecticut, Georgia, Indiana, Iowa, Massachusetts, Minnesota, Missouri, Nebraska, North Carolina, Northern California, Ohio, and Virginia)(2). A rigorous evaluation has been conducted throughout the implementation of the TAC, beginning with the pilot-test. (To learn about other adoption-competency trainings program, please see A Need to Know [Brodzinsky, 2013].)
The TAC Training
Working closely with a national advisory board, C.A.S.E. detailed eighteen areas of knowledge, values, and skills that mental health professionals must have to be considered “adoption competent.” Using these competencies, C.A.S.E. developed a comprehensive training program for postmaster’s mental health professionals.
C.A.S.E. ADOPTION COMPETENCY TRAINING FOR MENTAL HEALTH PROFESSIONALS: TRAINING SESSIONS
Introduction to Adoption Competent Mental Health Practice
Adoption History, Law, and Process
Clinical and Ethical Issues in Planning, Preparing for, and Supporting Adoption
Clinical Issues in Providing Therapeutic Services: Separation, Grief, Loss, and Identity Formation
Clinical Issues: Part 2: Attachment and Genetics and Past Experiences
Trauma and Brain Neurobiology
Family-Based Therapeutic Strategies: Coaching Adoptive and Foster Families
Adoptive and Birth Families
Adoptive Family Formation, Integration, and Developmental Stages
Openness in Adoption and Birth Family Culture
Race and Ethnicity
Adjunct Therapies and Cross Systems and Community Practice
Integrating Knowledge, Values, and Skills
TAC: Evaluation Highlights
The pilot program and all replications have been subject to ongoing, rigorous evaluation designed to assess training delivery, outcomes, and effectiveness by Policy Works, LTD.
TRAINING EFFECTIVENESS
TAC participants scored an average 37.87 points higher on post-tests than control groups of comparably qualified professionals not enrolled in the training (see table 10.1).
TABLE 10.1 TAC Evaluation Highlights
| Reasons surrounding the parents’ decision to build their family through adoption. |
Preadoptive experiences of adoptive parents play a large role in determining the later functioning of the adoptive family. Adoptive parents might have their own unresolved grief and loss issues, and special attention needs to be paid to the “fit” between parental expectations and the child. |
| The adoption story. |
A thorough “adoption history” is obtained through questions such as when was the child placed, at what age, where the child lived before joining the family (if the child was not placed at birth), and other related questions. |
| Impact of trauma. |
The neurodevelopment impact of neglect and traumatic stress in childhood is assessed. |
| Pre- and postnatal history. |
Parents are asked about their knowledge of the pregnancy and delivery (complications), birth family medical and social history, as well as the child’s developmental milestones. |
| Communication around adoption. |
The family’s comfort level with talking about adoption is assessed, including how the child’s adoption story was presented to the child, as well as the child’s age and reactions. |
| Attitudes and feelings toward birth family. |
Therapists need to know whether the adoptive parents met the birth parents, agreements around postplacement contact, and comfort level in acknowledging the importance of the birth family to the child. |
| Extended family members and social support system. |
Relationships with extended family members and social supports with regard to their acceptance of the adoption are assessed. |
| Entitlement and claiming. |
Questions are aimed at determining the parents’ sense of their right to parent the child as well as their efforts to “claim” their child. |
| The experience of being an adoptive family. |
Each family member’s feelings about being part of an adoptive family are explored, including their awareness of how their life has been affected by adoption. |
| Transracial and transcultural adoption. |
Therapists assess the family’s acceptance of themselves as a multicultural, multiracial family, including what the family has done to integrate the child’s racial or ethnic difference into his or her identity, and how the child has been prepared to handle racism and diversity in the larger social context. |
| Six tasks inherent to adoption. |
All family members must come to terms with the six fundamental dynamics of the adoption experience: reasons for adoption, missing or difficult information, difference, identity, permanence, and loyalty (Riley & Meeks, 2006). |
TRAINING OUTCOME: CHANGES IN CLINICAL PRACTICE
TAC participants are asked at the midpoint and conclusion of training to identify and comment on the aspects of practice influenced by information or insights gained from the training. On the basis of 410 responses that contained 1,920 separate narrative responses describing ways practices were influenced by the training, the following information was reported:
• All TAC participants to date report change in at least two of the six defined aspects of practice
• 55.65 percent report change in all five aspects at the individual clinician level.
• 56.85 percent report change in programming and services at the organizational level.
There is a sound and growing body of evidence that the TAC is a high-quality, effectively delivered training program that increases knowledge and changes clinical practices in ways associated with adoption competency.
Integrating Adoption Competency Into Practice
Meeting the diverse needs of adoptive families will require mental health providers to infuse knowledge gained through specialized adoption-competency training that influences one’s assessment protocol, diagnoses, treatment planning, and interventions.
In many clinical practices, adoption issues are not addressed in the assessment. At best, the question of adoption status may be posed simply as “Are you adopted?” For the therapist, the first step in affirming adoption is demonstrating their own comfort level in discussing the topic of adoption and the potential questions and feelings that may be raised in the assessment process (Riley & Meeks, 2006). The significance of adoption-related issues may be largely ignored or minimized by clinicians where the focus of treatment becomes the myriad of externalizing behaviors.
The assessment process is a thorough psychosocial evaluation integrating the complexities of adoption. The assessment may involve up to three sessions, including meetings with the parents, the child, and sometimes other family members and, if indicated, collateral and extended kinship family. Exploring the experience of adoption with both children and their parents must be an integral component of the assessment interviews. Assessments also include communication with the child’s school and other treatment professionals and a review of previous child welfare reports as well as educational, psychological, and psychiatric evaluations.
The assessment interview involves exploration of the following: Mental health providers must understand that adoption is a significant emotional event that cannot be ignored within the framework of offering mental health services affecting the adoptee, his or her family of origin, and the adoptive family. Although parents may be well intentioned or may have had access to preadoption education, adoptive parents often do not comprehend the causative factors of their child’s issues or behaviors and have an even less awareness as to the appropriate and effective interventions that would be helpful. Too often, healthy family systems are taxed so profoundly by children whose symptomatology is so severe that by the time they reach out for support they are perceived by the practitioner as the one who needs treatment, not the child. This is evident in families in which children have been exposed to prolonged periods of deprivation, maltreatment, and unpredictable stressors. In recent years, research has advanced our understanding as to the neurological implications of trauma and brain development and recommended treatment protocols influencing more positive outcomes for these children and familial stability.
It is the pervasive complexity of presenting problems, each child’s unique adoption experience, and the “temperament of the family system” that will and does require specialized adoption-competent mental health services from highly skilled professionals who have the knowledge and skills to treat these confounding issues. The nature, complexity, and severity of issues are best served by clinicians who possess a diverse repertoire of clinical knowledge and skills that are embedded in attachment theory, family systems theory, and ecological theory. Grounded experiences with an emphasis in child and family development that are trauma informed and culturally competent are more likely to be effective in supporting intercountry and transracial adoptive families.
In the past few years, there has been a heavy focus on the utilization of a specific, evidence-based protocol, but experience leads us to conceptualize a broader “clinical toolkit.” Research involving family surveys has stressed the need for services that are easily accessible and that allow families flexibility to access services that match their needs at different stages throughout the adoption life cycle (Atkinson & Gonet, 2007). The range of services will be the most effective when they are preventative, are supportive, and include an array of treatment interventions that are responsive to the family’s needs. Furthermore, it is essential that adoption-competent mental health services are embodied in a fluid, flexible time frame that leaves the door open versus services that are rigid and time limited. Such a malleable system of care has been linked to more positive outcomes for the families being served (Atkinson & Gonet, 2007).
Continuum of Needs
In any discussion of adjustment in intercountry and transracially adopted children, it is important to recognize that the vast majority of adoptees are functioning normally and that their adoptive parents are highly satisfied with their adoptions. Even among groups of adopted children coming from higher risk situations, such as institutions or those in foster care who were removed from abusive or neglectful homes, most children are in the normal range on standardized measures of behavioral and emotional problems (Howard & Smith, 2003; Howard, Smith, & Ryan, 2004; Rosenthal & Groze, 1992, 1994; Simmel, 2007).
Understanding the challenges and how they are manifest is a prerequisite to addressing them and maximizing children’s development to their fullest potential. Adoption scholars have identified critical developmental tasks confronting adoptive families as they work through core adoption issues at each stage of psychosocial development (Brodzinsky, Schechter, & Henig, 1992; Brodzinsky, Smith, & Brodzinsky, 1998; Hajal & Rosenberg, 1991; Schooler & Norris, 2002).
The needs of adopted children and their families after adoption fall along a continuum—some families face only a few challenges that they are able to handle successfully without professional help. A significant percentage, however, will struggle and seek counseling. Some families will seek help to weave the complexities of their children’s adoption experience through an intricate developmental lenses, whereas others may seek support to ensure their child has access to other adopted children so as to “normalize” their experience as an adoptee and not feel so alone, and yet other families will be navigating the journey of search and reunion.
Some adopted children come to their families from higher risk situations that bring additional stresses to any family adopting them. By contrast, some adoptive parents have characteristics that pose challenges for adoption adjustment. Their own unresolved loss and grief issues and “attachment injuries” may complicate their ability to support their child’s loss and grief issues and to help them successfully attach. Parents may come into placement with unrealistic expectations for themselves and the child. All of these challenges may lead to adoptive families seeking therapeutic counseling at various times throughout their lives.
Most parents express that adopting their child is a life-changing event. What often is not taken into account, however, is the need to adequately prepare parents for the ways in which adopted children manifest with a variety of psychological characteristics and behaviors that may differ significantly from other children. Many parents embark on the task of raising an adopted child ill prepared for understanding or coping with the behavioral manifestations of a child with a complex history.
According to a survey of adoptive parents’ training programs, the following top ten behaviors were identified as a reason to seek help (Freundlich, M. C.A.S.E. 2009, TAC Module 9):
• Anger Outbursts
• Lying
• Stealing
• Eating Disorders and Food Issues
• Sexualized Behavior
• Fire-Setting
• Sleep Problems
• Self-Destructive Behavior
• Wetting and Soiling
Within the framework of adoption-competent practice, parents are educated to understand the underpinnings of their child’s behavioral and emotional challenges as well as to understand that it is the parents, not the therapist, who plays the primary role in helping his or her child heal from past trauma. While engaging adoptive parents to be collaborative partners in treatment, it is imperative to remove viewing the family as pathological and to lift the blame from the parents: “We as adoptive parents are not to blame—we did not cause the problem, but we desperately desire to be an integral part of the solution” (K. D., parent of twelve adopted children). We must help adoptive parents understand how adoptive parenting is different from parenting by birth, particularly when the child has been exposed to the risks factors previously discussed. Engaging the family is essential to the child’s recovery and family well-being.
THERAPEUTIC APPROACHES AND CASE EXAMPLES
Armed with the understanding of all the potential factors and experiences that have affected clients when they walk through our doors, an adoption-competent therapist will be equipped to address the common themes that are most likely to present in almost all families they treat. In addition, they will have a repertoire of therapeutic approaches, strategies, and tools that have been found to be effective with intercountry and transracial adoptive families. Following a discussion of these themes and therapeutic approaches, we have provided several case examples to demonstrate how these themes and approaches are interwoven into the clinical treatment of these families.
Four Major Themes of Adoption-Competent Clinical Practice
LOSS AND GRIEF ISSUES IN INTERCOUNTRY AND TRANSRACIAL ADOPTIONS
Loss and grief is recognized as a if not the key issue in understanding clinical issues in adoption. Internationally adopted children, no matter what their age, embark upon their new lives facing loss—of their birth parents, birth siblings, extended birth family members, former caregivers, and supports (e.g., foster parents, orphanage staff, teachers, therapists, friends), genealogical continuity; racial, ethnic, and cultural origins; self-identity; the sense of “fitting in” in terms of looking like other family members; and privacy with regard to the adoption being “public.” These children have lost familiar smells, tastes, and sounds; the way they do things; material items; their language; and their daily routines.
In her book, Ambiguous Loss, Pauline Boss (2000) describes how grieving the losses in adoption are complicated because they are “ambiguous.” A child’s birth relatives may be physically absent but psychologically present (in their thoughts and feelings), as is often the case in intercountry adoption. Adoptive parents often need help in understanding how to identify their children’s grief and assist them through their grief issues. They also may need assistance in acknowledging the lifelong processing of the losses, including any they may have experienced themselves before becoming adoptive parents (Grotevant & Brodzinsky, 2009, TAC Module 4).
ATTACHMENT ISSUES IN INTERCOUNTRY AND TRANSRACIAL ADOPTIONS
Children adopted internationally have experienced the trauma of severed attachments. Many children have experienced multiple caregivers—birth family, foster family, and orphanage staff. The quality and the experience of the relationships with caregivers are as significant as the loss or separation from them. When a young child’s needs are not met in a consistent, responsive manner, a child’s ability to form healthy, loving attachments to adults can be severely compromised. Some children have never successfully attached to another adult; others have experienced insecure or ambivalent attachments. Combined with unresolved feelings of loss and grief, many children will go to great lengths to protect themselves from the very thing they need most to heal—attaching successfully to their adoptive parents.
Children who have learned to expect rejection, abandonment, and maltreatment at the hands of caregivers learn to depend on themselves and not trust adults. They usually experience serious fears of getting close to their adoptive parents, and many of their behaviors serve the purpose of maintaining emotional distance from them (Malchiodi & Crenshaw, 2014).
Older transracially adopted children may experience many challenges around feeling like they truly fit in or belong to their families when they look so different from them. Ethnic, racial and cultural differences between their adoptive families and previous experiences with caregivers—birth family, foster families, and orphanage staff can impede their ability to adapt and attach to their new families.
It is equally important when addressing attachment issues to assess the role of the parents’ own attachment histories as it affects their ability to support healthy attachments for their child (Hughes, 2009) Adoptive parents often are surprised to find that racial differences are affecting their ability to attach to their new children, regardless of age. Parents with either birth children or same-race adopted children are often especially vulnerable to this unexpected challenge. In addition, transracial adoptive families are affected by societal reactions. Negative responses to their families can seriously undermine a family’s sense of validity as a family, which can further impact attachment.
TRAUMA ISSUES IN INTERCOUNTRY AND TRANSRACIAL ADOPTION
As we have discussed throughout the chapter, many of the children and adolescents we treat come from histories embedded in trauma. We have referred to “trauma histories,” but many children have experienced what is termed “complex trauma.” Complex trauma is defined by Courtois and Ford (2009, p. 1) as “including traumatic stressors that (1) are repetitive and prolonged; (2) involve direct harm and/or neglect and abandonment by caregivers or ostensibly responsible adults; (3) occur at developmental vulnerable times in the victim’s life, such as early childhood; and (4) have great potential to severely compromise a child’s development.” Children adopted from abroad have likely experienced several traumatic breaks in attachment. Preadoption experiences, especially in orphanage care, suggest the possibility of having experienced emotional neglect (lack of nurturance and stimulation), physical neglect (lack of adequate nutrition and medical care), sexual and physical abuse, and witnessing violence and abuse.
Extensive research substantiates the physiological changes in brain structure and chemistry with profound and prolonged effects, compromising all aspects of development. Early trauma will affect problem-solving skills, social awareness, ability to learn, attachment, physical health, self-esteem, and emotional regulation. It can have an impact on the developmental milestones that every child must master for healthy emotional and intellectual growth.
PARENTING A CHILD OF A DIFFERENT RACE
Research indicates that when racial minority youth have personally explored the meaning of their racial membership for themselves, have a positive view of their race, and a secure identification as a member of that race, they have higher self-esteem and more positive mental health outcomes than youth who are not able to these steps (Seaton, Scottham, & Sellars, 2006)
Transracial adoptive parents that are seen in treatment likely will fall somewhere on a continuum with respect to their understanding that “race matters,” and that in addition to all of their other parenting tasks and responsibilities, they have unique responsibilities to this important fact. Some families will deny that race is important (“I am colorblind” or “love is enough”); others may sense that race is important, but they may not quite know how or what they should be doing. On the other hand, some transracial adoptive families may place greater emphasis on race than their child is comfortable with.
Therapists must help parents understand the importance of helping their children with “racial socialization,” which is critical to fostering children’s positive racial identity. Parents may be unaware of the unintended ways they may compromise their efforts to instill in children the values of their race. Racial socialization includes helping parents learn how to help their children cope with racism. This can be a daunting task because white parents frequently do not have the life experiences that equip them to prepare their children for racism.
Karen, adoptive mother of 16-year-old Kyra adopted from Ethiopia at age 6 years, was uncomfortable when Kyra started spending time at her friend Emily’s house. Emily is African American, with two older teen brothers. Karen wondered whether there was proper supervision. Upon exploration in therapy, it became clear that Karen had not really considered that her daughter might “date” a black man. She also admitted that she would not have questioned her daughter’s judgment or safety if Emily’s family was Caucasian.
Seventeen-year-old Mark, adopted as an infant from Korea, was traveling with his Caucasian adoptive family in North Dakota one summer. Stopping at a restaurant, it seemed to Mark that it was taking an awfully long time for his family to be seated. He began to notice other “parties” being seated ahead of his family who had entered the restaurant after his family. Mark commented to his mother that he thought maybe something racist was happening. His mother dismissed his concerns and told him that he was being ridiculous and paranoid. As more time passed, Mark’s father inquired about the wait and was told their table would be ready soon. It was not. Rather than confront the situation, Mark’s family left and found another place to eat. No word was spoken about this incident until Mark brought it up in therapy. Mark’s parents were helped to acknowledge that Mark’s perception was accurate. His mother cried as she said she just felt so helpless about how to handle what had happened or even to talk about it, not wanting to either believe it or hurt Mark. Therapy helped Mark’s parents open up the dialogue and plan for how they would work together to deal with any future racist incidents.
Therapists can support transracial adoptive parents in talking with their children about racial issues, even if their child does not bring up the subject. Parents can use natural opportunities, such as a television programs or newspaper articles that talk about race in some way. Therapists can help parents develop ways to let their child know that they feel comfortable discussing race, including the positive aspects as well as the difficult topics.
If their child is a victim of a racial incident or as problems in the community because of the unkind actions of others, therapists can teach parents ways in which to support their children. The therapist can help parents develop tools that they can give their children to deal with these situations. Above all, the therapist can help parents respond to their child’s hurt feelings by allowing the child to talk about the experience with the parent and acknowledging that the parent understands (Leslee et al., 2009, TAC Module 12).
A therapist can support transracially adoptive parents in connecting their child to people who reflect the child’s racial and ethnic heritage. Therapists can encourage families to participate in adoptive family support group events that often provide places where children will meet and interact with other children and adults of their own racial and ethnic heritage.
EFFECTIVE THERAPEUTIC APPROACHES, TOOLS, AND STRATEGIES: TRANSRACIAL AND INTERCOUNTRY ADOPTIONS
The following, although not exhaustive, are treatment approaches, models, and interventions that have proven to be effective in treating intercountry and transracial families. Many of these tools can be incorporated easily into the therapist’s previous clinical training and clinical constructs in which they practice.
Psychoeducation for Parents
Much of the work with parents is helping them understand what is behind the troubling, distressing symptoms, and behaviors of their children are demonstrating. For adoptive parents, trying to understand a child’s history can be heartbreaking. Psychoeducation for parents is provided in therapy around key aspects of the adoption experience for children and adolescence, including the following:
• How to understand the ways children and teens process adoption from a developmental perspective.
• How to talk with children and teens about adoption (telling the adoption story) from a developmental perspective.
• How to understand the implications of trauma experiences or histories on brain development and behavior, as well as the impact of institutionalization.
• How to understand the impact of prenatal drug and alcohol exposure.
• How to help children and teens process loss and grief.
• How to employ effective parenting strategies, including appropriate discipline with traumatized children.
• How to promote attachment with their children.
• How to promote self-esteem and positive racial identity through racial socialization.
• How to become a multiracial family, including how to incorporate their child’s ethnic, cultural, and racial heritage into the family experience.
• How to help children cope with racism.
Theoretical Basis for Dialectical Behavior Therapy
The focus of dialectical behavior therapy (DBT) is on helping the client learn and apply skills that will decrease emotion dysregulation and unhealthful attempts to cope with strong emotions, difficulties that many internationally adopted children and adolescents experience as a result of their traumatic beginnings. Usually, DBT includes a combination of group skills training, individual psychotherapy, and phone coaching, although there are exceptions. Parents involved in DBT are asked to monitor their child’s symptoms and use of learned skills daily, and their progress is tracked throughout therapy. Four main types of skills are covered in DBT skills training: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness (Dimeff & Linehan, 2001).
Trauma-Informed Treatments
TRAUMA-FOCUSED COGNITIVE BEHAVIORAL THERAPY
Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based treatment approach shown to help children, adolescents, and their caregivers overcome trauma-related difficulties. It is designed to reduce negative emotional and behavioral responses following child sexual abuse, domestic violence, traumatic loss, and other traumatic events often experienced by internationally adopted children.
The neurosequential model of therapeutics (NMT) developed by Dr. Bruce Perry and Christine Dobson at the Child Trauma Academy in Houston, Texas, is most widely used treatment with traumatized and maltreated children. For more information about this approach to assessment and clinical intervention, see chapter 5, “A Neurodevelopmental Perspective and Clinical Challenges.”
W.I.S.E. UP!SM
During the middle childhood years, adoptees encounter questions and comments from peers about adoption. In addition to feeling uncomfortable and upset, these questions may trigger additional feelings of loss and grief. These questions from the “outside” may trigger questions that children have “inside” that they may not be developmentally ready to think or talk about. For children in intercountry and transracial adoptions, they can be especially troubling when they refer to those aspects of the child’s adoption story, or reflect racist attitudes and bias. Some of the questions and comments that children may hear are as follows:
“Who/where is your real mother? How come she didn’t keep you?”
“I hear you were left in an orphanage. What was wrong with you?”
“How can that be your mother? Her skin isn’t dark like yours.”
“How much did your parents pay for you?”
“Why are your eyes so weird/strange?”
“Do you speak Korean?”
“I think Asian girls are really sexy.”
C.A.S.E developed an empowerment tool that can be used to prepare children for adoption-related questions and comments. W.I.S.E. UP! can effectively assist children and teens manage these intrusive, insensitive, extremely hurtful situations. Children learn that they can choose how to respond with four options: “W,” walk away or ignore what is being said; “I,” it’s private and I don’t have to answer; “S,” share something about their adoption story; or “E,” educate others about adoption in general without sharing personal information. Children and teens explore their feelings about these questions and in which circumstances they are likely to choose one option over another or any combination of these four options.
The W.I.S.E. UP! Powerbook may be used as a clinical tool with families and children to help them prepare to effectively manage the challenge of unwanted questions or comments. Each book includes an insert with guidelines for clinicians for using the W.I.S.E. UP! program with children in therapy. Instructions for parents’ use with children are included as well.
GROUP THERAPY
Group therapy has a distinct advantage for adopted children and teens: It provides a social milieu for growth and emotional healing; it provides opportunities to identify with other kids and normalize experiences. “I’m not alone!” helps children and teens release stigma and shame, and it validates the universality of their issues. Groups may offer the opportunity to meet other transracially or internationally adopted children and see how they are part of a “larger adoption community.” C.A.S.E. uses a scripted group schedule for its group therapy. For more information, see Beneath the Mask: Understanding Adopted Teens (Riley & Meeks, 2006).
Beneath the Mask was written for both parents and clinicians. It provides an in-depth understanding of the developmental challenges and psychological issues that adopted adolescents and their families experience. Clinicians will find a step-by-step approach to conduct an adoption-competent clinical assessment, effective clinical strategies, treatment resources and therapy tools. Numerous case examples are provided that illustrate the complex dynamics and common themes presented in clinical work with intercountry and transracial adoptive teens and their families.
CASE ILLUSTRATION: TOO MANY LOSSES TOO SOON
History
Lida is a 16-year-old girl who was adopted from Russia at the age of 7. Her parents had a birth son Adam who was 3 years older than Lida. Lida lived with her birthparents for the first 4 years of her life, was removed due to neglect, and placed in an orphanage for 3 years. Lida’s birth parents were both alcoholic. Lida’s adoptive parents described the conditions of the orphanage as “horrific.”
Shortly after having her children removed, Lida’s birthmother died from alcoholism. Lida’s birthfather was still alive at the time of her adoption. Lida’s adoptive parents were told by the orphanage staff that Lida and her older brother Alex, who was living in the same orphanage “were not close.” They later learned from Lida that this was not true—that she and her brother were very close, and that it was extremely traumatic to have been separated from him. Lida told her parents that Alex had instructed Lida not to talk to them when they came to adopt her in the hope that they would not take her away.
Presenting Problem
Lida entered therapy when she was 13.5 years old. Her parents were concerned that her early life experiences were causing the behaviors affecting their daughter but could not obtain validation from other professionals they had seen. The presenting issues were lying, stealing, defiance, poor boundaries, attention-seeking behavior, and difficulty with social relationships. Lida’s parents had sought therapy in the past for their daughter and described it as being nonproductive with little change in presenting issues. Parents were recommended to employ “tough love” strategies to “gain control as parents” and “show their daughter that they were in charge.”
When asked her view of what was happening, Lida shared, “I have anger issues and I lie sometimes.” She identified sibling conflicts and the desire to get along better with her brother, that she loved him despite his hurtful comments to her (i.e., “I wish you were never born”), which she said, “force me to get revenge!” Lida admitted to being very worried that this difficult relationship was all her fault. She recalled that the first thing she did when she came from Russia was hit her brother, and she felt guilty and confused by her actions.
During elementary school, Lida was falling behind academically. Following an assessment conducted through her school when she was in the third grade, she was diagnosed with learning disabilities that affected her reading comprehension and fluency. She receives special educational supports to support her learning issues.
Treatment with this family included referral for a neuropsychological evaluation to further assess the impact of postinstitutionalization and in utero alcohol exposure, as well as individual therapy with Lida, and family therapy with and without Lida present.
The evaluation reflected the implications of the 3 years that Lida lived in an orphanage, revealing deficits in executive functioning, and in language development—all of which were contributing to her poor academic performance. Furthermore, having expertise in working with postinstitutionalized children, the evaluator also shared her concerns regarding the attrition of Lida’s Russian language before English language had developed. This often presents a significant educational challenge for school-age internationally adopted children as they have to learn a new language concurrently with new academic content. This understanding provided much needed clarity to Lida’s parents who desperately wanted to help Lida succeed academically but had been told by other professionals that Lida was just lazy.
Individual Treatment Tools and Strategies
A few weeks after starting therapy, Lida blurted out that she wanted to kill herself in math class after becoming frustrated while taking a quiz. She was seen immediately by her therapist to assess risk of self-harm. Lida revealed that she was feeling sad because, a few months before starting therapy, her friend’s mother died and she had attended the funeral. The funeral triggered thoughts about her birthmother and the fact that she had not been able to attend her funeral. Lida never had the chance to say goodbye. Tears rolled down her face as she allowed herself to talk about her profound loss and express her conflicted feelings surrounding her “abandonment” and disloyalty. Lida had never shared these feelings with anyone.
Therapy supported the acknowledgment and processing of her grief. With regard to disloyalty, Lida feared sharing her grief with her parents as she worried that they would feel she was not grateful about being adopted and that she loved her birth family more than them. Lida described crying herself to sleep at night as she tried desperately to remember what her birthmother and brother looked like. It was impressive to learn that Lida had been keeping a secret journal that helped her to soothe herself and process her difficult and bewildering history. Her writings revealed her significant trauma and intense feelings of loss and grief. She wrote about terrifying incidents involving her birth parents’ drinking, which included memories of physical and verbal aggression as well as a fire that accidentally was set by her mother.
One of the clinical tools that have been extremely helpful when unresolved loss is present is the creation of a Loss Box. Although this tool has been used in other treatment modalities, we have found it to be useful in guiding children and teens through the psychological task of grief work.
Lida was open to this process and focused her attention on identifying the loss of her birth family—a powerful memory for internationally placed children whose early years were spent with their birthparents. Unfortunately, as with many children adopted internationally, Lida did not have any pictures of them. With the help of the therapist, Lydia was able to “recreate” from memory and use collaging as a tool to make a “snapshot” of what she remembered her birth parents looked like, and she placed those pictures in the box. Lida filled the box with pictures of the town she was raised in as well as the orphanage, which she found on the Internet. She also used clay to create symbols that represented her memories as a child in Russia.
In therapy, Lida was also provided with the opportunity to explore the use of rituals as a way to memorialize her birthmother. She chose to tie a message to a to a helium balloon to be released every year on the anniversary of her mother’s death.
Family Treatment
The focus of the work with Lida’s parents had several goals: (1) to help them understand the underpinnings of their daughter’s grief and how grief can be behaviorally manifested in children; (2) to equip the parents with knowledge around parenting a child with a trauma history to enable them respond to Lida’s challenging behaviors in appropriate, effective, and healing ways; and (3) to help Lida share her feelings with her parents.
In individual treatment, Lida was able to unpack the sadness she felt that was underlying her behavioral difficulties. In sessions with her parents, she was able to share her feeling of loss and grief, her need to remember and acknowledge her birth family, and her fears around getting close to others. Lida and her parents explored her unconscious fear of getting close to them and of losing them as she did her birth family. Her defiance and acting out behaviors served the purpose of pushing them away, which also reaffirmed her sense of inadequacy and her belief that she was “unworthy.”
In embracing Lida’s grief, Lida’s parents were able to explore with her the possibility of searching for her birth brother in Russia. Although her mother was supportive, Lida’s father needed support to resolve his fear that such an undertaking might overwhelm Lida and exacerbate both her behavior and the secure attachment she was continuing to build with her parents.
Individual and family therapy also addressed the impact of prenatal exposure to alcohol. Lida was never formally diagnosed with fetal alcohol spectrum disorder, but it is likely that this exposure contributed to her learning and executive function challenges, including impulse control and judgment. (http://www.cdc.gov/ncbddd/fasd/facts.html)
CASE ILLUSTRATION: CONNECTIONS
History
Michael, age 10, was born in Ethiopia and adopted at the age of 7 years old by his parents who have a 14-year-old daughter by birth. His adoptive parents are both Caucasian. Michael was raised by his birth mother until the age of 4 years old when she died of AIDS. Michael witnessed his birth mother’s decline in health and was with her in the hospital when she died. Before being placed in an orphanage, he lived for a year at this military field hospital where he was sexually abused and witnessed blood, death, and dismemberment on a daily basis.
Presenting Problem
Michael was referred at age 9 years old, following two inpatient hospitalizations for violence against his peers, homicidal comments, suicidal thoughts, and running away. Michael’s parents came to therapy feeling hopeless and stating that they were thinking about dissolving their adoption. Parents shared that hospital staff were recommending residential treatment and inferred that he likely could not attach because of the extent of his early trauma.
Treatment Tools and Strategies
While helping adoptive parents explore their thoughts of relinquishment is important, it is equally important to give them hope that through the process of treatment, a child can be helped to turn around and learn to trust and bond with them. Too often, parents who adopt children internationally who present as Michael did lack the knowledge they need to be effective as parents. Their ability to understand and feel hope can help them meet the challenges. Parenting a child with a history of traumatic experiences requires a skill set that is not intuitive. The therapist shared with Michael’s parents that their responses to Michael need to be counterintuitive. When someone comes at us with anger, hostility, or aggression, our knee-jerk response is to fight or fly, which is exactly what traumatized kids are doing all the time. The therapist serves as a teacher for the parents providing them with psychoeducation about complex trauma and posttraumatic stress disorder (PTSD).
The treatment plan for Michael and his family focused on using the TF-CBT to address the issues of complex trauma and PTSD. A significant part of TF-CBT is psychoeducation, teaching the parents as well as the child about the facts of expected behavior, such as the ones they were witnessing. The parents learned that the impact of trauma on Michael’s brain development resulted in the fact that his chronological age was different than his true emotional age—which was closer to 4 years old. His parents became more hopeful about Michael’s ability to heal as their understanding increased around his unusual and destructive behavior. Play therapy was utilized during TF-CBT sessions to enhance the trauma-focused goals.
Therapist met with the parents for a month before working with Michael. Daily, he would threaten to kill them, sometimes when they were trying to get closer to him emotionally, but especially when they were having disagreements. He seemed to constantly miscue threats in his social life. It did not matter if people were trying to be friendly or if they were simply indifferent toward him. He would read their facial expressions, body language, and speech as hostile. He automatically would go into the normal “fight, flight, or freeze” mode that all people exhibit when a perceived threat is at hand. Through the use of role-plays, therapists discussed ways in which the parents could work on their emotional regulation in response to his behaviors.
When Michael began coming to sessions with his parents, the therapy continued to focus on building a secure attachment through play-based interaction. Michael loved to spin in circles and swing for hours, often isolated himself from other children, and would engage in what looked like obsessive, repetitive play. Prior assessments concluded a diagnosis of autism.
It was quite clear that Michael was not autistic but that his body and brain were craving repetitive and consistent sensory stimuli. Consistency and repetitive actions can assist with rewiring the brain when children have experienced neglect and trauma. When it became clear that Michael was experiencing sensory integration issues as well, a referral was made to an occupational therapist. The therapist encouraged the parents to spin with him and to join in his play to engage him before trying to direct him toward playing or doing something that they wanted him to do. Michael’s parents began understanding that his play calmed his sensory system. It was important that the parents understood and joined with him in this type of play as a way to work toward establishing a more secure attachment. As play therapy continued to enhance child and parent interaction, filial therapy, Theraplay®, DIR®/Floortime, and parent–child interaction therapy techniques all were utilized. Sand tray therapy was also used with Michael (see figure 10.1). Many children are unable to vocalize their emotional state as a result of trauma involving extreme neglect or abuse. Incorporating the element of a familiar medium, the sand, allows a child to instantly achieve a sense of comfort and security. With little instruction from the therapist, the child is free to play and develop his or her own expression of situations. Often, the children will experience a sense of independent play and will begin making assumptions and behavior changes without cues from the therapist. This method of therapy serves as a valuable and powerful outlet for children and an incredibly insightful method of gaining access to their traumatic experiences.
FIGURE 10.1 Sand-tray therapy with Michael.
As the parents’ level of anxiety decreased, so, too, did their son’s. Michael seemed increasingly settled each time they came for sessions. His parents were noticing that his aggressive behaviors were decreasing and they began to see a different behavior in him, including smiles and occasionally laughter. The parents said for the first time since they had adopted him 2 years ago, he suddenly was appearing to be more relaxed and started looking at them more and sustaining eye contact. He was more engaged and became more creative in his play with his parents and peers. He was allowing family members to physically close to him; he permitted hugging, rubbing his back and shoulders, holding hands, and kissing on the cheek. The connections had begun.
CASE ILLUSTRATION: HEALING THE HURT
History
Julia is an active and engaging 8-year-old girl who was adopted from Guatemala at 23 months. She was born with a cleft palate and has had several corrective surgeries since coming home. Nothing is known about the circumstances surrounding Julia’s relinquishment. Julia was placed in an orphanage as a newborn, and then had three foster home placements before returning to the orphanage before her adoption.
Presenting Problem
Julia’s adoptive parents sought services from C.A.S.E. when Julia was 6 years old because of excessive tantruming during which Julia could become physically aggressive, often hitting, kicking, and biting her mother. In addition, Julia’s parents were concerned about poor sleep habits, saying Julia continued to wake every 2 to 3 hours at night. At the time treatment began, Julia was receiving preschool-based speech therapy services to address a diagnosed expressive language delay.
Treatment Tools and Strategies
The focus of treatment has been on supporting Julia’s parents to address challenging home behaviors, to help Julia better regulate her affect and behaviors while learning to utilize age-appropriate strategies for managing feelings of anger and frustration, and to support Julia in beginning to explore her adoption story. Julia’s parents have both been engaged in treatment. Initially, however, her mother was much more open to psychoeducational interventions focused on increasing the parents’ understanding of the developmental trauma and its impact on current behavior and socioemotional development as well as how early losses, deprivation, and inconsistent or unpredictable care may influence one’s ability to regulate affect and tolerate frustration. Although Julia’s father loved his daughter, it was difficult for him not to view much of her misbehavior through the lens of his own childhood: “manipulative, willful, disrespectful behavior received strict and firm punishment.” He saw his wife as being too soft. Treatment helped him adjust his understanding embracing a more “positive parenting style,” which is linked to positive adjustment in internationally adoptive families when their children have histories of maltreatment.
Julia’s parents have worked hard to set age-appropriate (socioemotional age, not chronological) expectations for their daughter and have become skilled at understanding Julia’s negative behaviors as a way of expressing strong and often-overwhelming feelings and fears that she has not been able to articulate more directly. Dad was able to respond with more warmth and positive discipline responses and received ongoing support in treatment to recognize his own triggers.
When Julia entered kindergarten, several months after beginning treatment, the school expressed concern about Julia’s academic performance and reported that she struggled with transitions, had difficulty during unstructured class time, and could be impulsive and aggressive with her peers. Both the school and pediatrician felt that Julia met the criteria for attention deficit hyperactivity disorder (ADHD). As a result, and because of some continued challenges at home, a comprehensive neuropsychological evaluation was recommended to help paint a more complete picture of Julia’s academic and emotional strengths and challenges.
The evaluation revealed significant speech and language delays and indicated that Julia also showed delayed development in early reading, writing, and math skills. Although challenges were noted in Julia’s overall executive functioning, the criteria for ADHD were not met. The psychologist who conducted the testing believes that much of the impulsivity and poor problem solving is the result of social immaturity and a “primed stress response” system that better fits the diagnostic criteria for PTSD and children who were adopted internationally with histories such as Julia. As a result of the evaluation, Julia’s parents decided to move Julia to a smaller, private school where she repeated her kindergarten year and received more intensive, targeted speech and language services with a private practitioner. Julia began thriving in school as her increasing social emotional maturity and blossoming language skills allowed her to better manage the social and academic demands of school.
Much of the individual therapy work with Julia, given her age, has been through play. Several consistent themes emerged in her play throughout treatment, focusing mostly on safety and protection, as well as sickness and healing. Julia has engaged in play with the “bad guys” since beginning treatment, and this play has evolved tremendously as Julia has begun to integrate her adoption story and early life experiences. A baby always has been at the center of her play, and notably, Julia chose a baby of color reflecting her racial connection as a transracial adoptee. (Children as early as 2 and 3 years of age begin to notice differences among people. They have learned to classify, and they tend to sort based on color and size. What we know is that young children cannot decipher multiple racial classifications and can get confused about the names of racial groups and the actual color of their skin. The therapist acknowledged how the baby’s skin color was the same as Julia, and future work will help Julia understand how people with different skin tones can be part of the same family.) During play, there were always “bad guys” who would try to hurt the baby. At first, the baby did not have a protector, and Julia’s play was disorganized and chaotic. Over time, Julia used animal figurines to help keep the baby safe, not allowing the “bad guys” to hurt or take the baby. More recently, Julia has become the “protector,” ensuring that no harm comes to the baby during play.
Medical play has been the second area that has been seen consistently in treatment. Julia always takes on the role of the doctor, performing many of the same surgeries that she herself has had to endure. She is meticulous in her role, often engaging the therapist and her parents as nurses and other doctors to help with the procedures. Julia increasingly engaged in this type of play following a surgery she underwent during her time in therapy.
Play has been incredibly healing for Julia, as she has been able to take on the role of “protector” and “healer.” She has been able to assume roles that represent “power” and “control,” and in doing so, she has begun to work through some of the feelings of helplessness, which were associated with her life in Guatemala. Julia is thriving socially and academically in school. Her parents have seen great improvement in her ability to tolerate and manage frustration and report increased emotional maturity in many areas. Treatment continues to work on helping Julia’s parents address challenging home behaviors and allows Julia the opportunity to continue to integrate and process her story.
CASE ILLUSTRATION: SEARCH FOR SELF
History
Lui Li was adopted at age 16 months from an orphanage in China following three other “living situations.” Little information regarding early history was available other than that Lui Li had been in an orphanage after being abandoned. At the time of placement, Lui Li was malnourished and had a history of scabies that resulted in constant scratching that continued beyond the treatment of scabies. In 2006, Lui Li began pulling her hair compulsively, which resulted in significant hair loss.
A psychological evaluation was conducted in 2001, which reported that Lui Li is a “complex child with many resources and strengths but also with special vulnerabilities and ‘failures’ in adaptation. Her adjustment falls within the neurotic realm, but is complicated by her tendency to somatization and perhaps budding characterological issues. She is a quite sensitive, imaginative child whose current cognitive functioning does not reflect her optimal level of performance … she shows limited ability to regulate affect which increases her predisposing to anxiety and depression.” Nowhere in this evaluation is adoption ever mentioned or the implications of early deprivation and trauma on neurodevelopment. The recommendation was for “intensive individual intervention.” Lui Li’s mother reported that following this report, her daughter was involved in “traditional therapy” for more than 3 years with minimal progress.
Early developmental milestones for Lui Li are hard to identify because of placement age. This lack of information can pose challenges for professionals working with internationally placed children, often having to formulate a diagnosis and treatment plan without historical information. Her parents reported that she was not speaking Chinese at placement and seemed to understand English fairly easily. Her first intelligible statement was “do it myself.”
Lui Li walked at 16 months, and it was not clear whether she had walked independently before adoption, but parents noted that she was well-coordinated and had strong fine motor skills. Lui Li was reported to be a healthy eater but had a history of hoarding food.
Presenting Problems
Lui Li was referred for therapy at 12 years of age as her parents were concerned about her not being as “close” to her mother as she would like her to be.
Lui Li presented with chronic anger outbursts, distractibility, oppositional defiant behaviors, depression, anxiety, and self-injurious behaviors. She clawed her skin with fingernails on extremities and stomach, used razors for cutting, and pulled large clumps of hair out of head. Hair pulling began in spring 2006. In 2006, Lui Li was diagnosed by the collaborating psychiatrist who confirmed the diagnosis of trichotillomania and anxiety disorder, and prescribed Lexapro to treat anxiety.
Lui Li was described as exhibiting anger for no clear reason, being controlling and manipulative, having a poor understanding of social cues, lacking empathy for others, and being socially abrasive, all resulting in her having a hard time making and keeping friends. She also would lie with no remorse. Teachers described her social interactions as ranging from bullying to being overly or inappropriately silly. In the classroom, she had trouble managing her behaviors.
Lui Li’s parents were concerned that she was not able to demonstrate a variety of coping skills other than anger or “checking out.” Lui Li reportedly cried daily and was unable to describe her feelings following these “crying storms.” Sometimes she was seen as being “unresponsive” with no change in consciousness or mental status. She was hypervigilant regarding safety and extremely cautious in new situations.
At the time of intake, Lui Li presented as a young girl who was overly intense, had low levels of adaptability, lacked trust in others, and could not tolerate seeking comfort from anyone. She had a hard time bouncing back when distressed with high emotional reactivity. She had a negative view of herself and took her pain out on others and herself.
Treatment Tools and Strategies
Lui Li was seen in therapy from 2006 to 2011, at which time she was in the 11th grade. It is critical to understand Lui Li’s behaviors in context of the contributing factors: early familial losses, environmental instability, and suspected abuse. All of these factors can significantly disrupt developing stages of cognitive and psychosocial development, including the development of attachment to parental figures, positive self-image, and trust in others. Lui Li’s history and responses suggest an attachment disorder that was affecting family and peer relations. It was also necessary to view her behaviors through a neurodevelopmental lens, regarding her stress response. As she inaccurately perceived “threats,” her fight or flight response was easily activated, and she was slow to soothe herself, expending a level of energy that resulted in emotional depletion. Lui Li would talk about how tired she was and how hard she worked at school to try to focus on her work. Given the complex clinical presentation, early treatment protocols consisted of DBT to treat the self-injurious behaviors as well as a behavioral treatment approach for the treatment of trichotillomania.
Lui Li’s hair pulling resulted in significant hair loss, which added to her social isolation and feelings of difference. “I started to pull when I was 11 years old. In time, I had several bald spots, which I could no longer hide. All the hair form my crown was gone and my mom started to worry. She told me that I was going to see a therapist and I started to yell and said, ‘NO, I DON’T WANT TO GO TO ANOTHER STUPID THERAPIST.’ A few days later, we arrived at C.A.S.E. and my therapist helped me with my hair pulling and other issues like adoption. I learned so many things about ‘trich’ and strategies to manage it. I learned that it was not my fault, and I should not be ashamed. I was not the only person in the world who had it. Remember it’s not your fault.”
As issues of attachment, trauma, and trichotillomania (TTM) were effectively addressed, Lui Li was able to unearth and acknowledge her feelings of betrayal towards her birthmother. “She left me to figure life out on my own.” “She abandoned me, left me in the middle of a field, what kind of person would do that?” “There must have been a child that was better than me.” “You throw away garbage not a baby.” “Most of the time I feel worthless, sad and unwanted.” Lui Li felt conflicted and guilty for not feeling “grateful” that she was adopted, that she had been “saved.” “My cutting helps me to put my pain into something physical.” Given a safe place to hold these powerful emotions, Lui Li went on to reveal her feelings of difference as she was only one of four Asian kids in her grade. “I feel so different. I don’t look like my parents, they don’t look like me. Kids stare at me, they call me names. I’m not sure where I fit in.
One day Lui Li brought the lyrics of a song, “Reflections,” by Christina Aguilera.
Look at me
You may think you see
who I really am
But
you’ll never know me
Every day, is as if I play
apart
Now I see
If I wear a mask
I can fool the
But I cannot fool
my heart
Who is that
Girl I see
Staring straight back at me?
When will my Reflection show
Who I am inside?
I am now In a World
where I have to Hide my heart
And what I believe In
But somehow I will show the world
What’s Inside my heart
And be loved for who I am
The line “Who is that girl I see, staring straight back at me” was the foundation for the mask work. Lui Li deeply pondered how she possibly could figure out who she was when she had no idea who brought her into the world, what they were like, or how she was like or different from them. This overwhelming vastness of unanswered questions shadows the critical developmental milestone of identity formation. Further complicating her quest for identity was the role being transracially adopted played: “What does it really mean that I am Asian?” Lui Li was able to honestly tell her parents about the extreme racism and bullying that she was experiencing, and the assumptions people made about her because of the color of her skin. In therapy Lui Li shared her mask with her parents, which revealed the pain she endured as reflected in the color black, but also her slow acceptance of which she was using pink and glitter to represent aspects of herself that she was slowly embracing through her therapy.
Lui Li terminated therapy in 11th grade, feeling that she had grown in so many ways: “I don’t see myself as a kid that no one wanted, I have a family.” She is currently in her second year of college, doing extremely well. She continues some hair pulling but as she says, “I have learned to manage my trich and continue to use the problem solving skills I learned, especially around dealing with my feelings in a different way.”
CONCLUSION: FINDING AN ADOPTION-COMPETENT THERAPIST
Intercountry and transracial adoptive families need and deserve access to professionals equipped to address their unique needs. Advocacy for congressional funding for adoption-competent postadoption training and support services is a priority for C.A.S.E. and our partner organizations.
Every day C.A.S.E. gets calls from desperate parents around the country searching for a therapist who understands adoption. We hear stories of time wasted with mental health professionals who often not only were not helpful but also exacerbated a family’s distress. We feel for these families’ frustration and offer several ideas to help locate an appropriate therapist. In addition to the following resources that may help identify appropriate resources, parents can learn the questions to ask to determine whether a therapist is adoption competent and specifically has the knowledge, training, and skill to effectively treat intercountry and transracial adoptive families.
Parents can consult the following resources for therapist recommendations:
• Agency social workers involved in the child’s adoption
• State or local mental health associations
• Public and private adoption agencies
• Local adoptive parent support groups, including ones from your child’s country of origin or for transracial adoptive families (www.pact.org)
• Specialized postadoption service agencies
• State adoption offices
• National and state professional organizations
This chapter affirms that we are making strides by acknowledging “adoption competency” as a valued body of knowledge that is essential when treating those whose lives have been touched by adoption. During a recent training, an adoptive mother began to talk about her teenage daughter who was struggling. This mother shared that they had seen many therapists and that her daughter was experiencing bullying at school related to racism and adoption. She wanted advice as to how to find a therapist that was adoption competent. The mother said that her daughter had written the following poem, and she obtained her daughter’s permission to share it. Hopefully, this chapter will have encouraged more practitioners to see the value in seeking adoption-competent training to address the complexity adoption presents with young people like Maya who have so much to say if we will listen.
WHERE I’M FROM
Maya, age 12
I am from the town of Animal Lovers and gardeners
From Forever 21 and H&M
I am from the town full of flowers
beautiful, colorful
smelling like sweet pollen
I am from the basil
the tomatoes
red and shiny
I am from compliments and kindness
from “you should treat others how you want to be treated”
to the “you should treat everybody equally”
I am from the Shabbat blessings on Fridays
I am from Huizhou, China
from rice and noodles
from the mixed cultures and traditions
from the family members that bring the traditions to life
I am from a home of different cultures and unique family.
DISCUSSION QUESTIONS
1. What are the mental health challenges presented by transracial and intercountry adoptees?
2. What is the relationship between the adoptee’s preadoption history and experiences and their mental health challenges?
3. What questions can you integrate into your assessment process that would enhance the adoption competency of your work with adopted children, youth, and their families?
4. Why is it imperative that parents be involved in treatment? What evidence-based and evidence-informed treatments are effective with this population?
5. How are racial, ethnic, and cultural differences between the adoptee and family best addressed in treatment to result in positive outcomes around identity formation and racial socialization?
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