Transcript Core Clinical Issues in Foster Care and Adoption Advanced Practice Certificate Program in Adoption and Foster Care Competency Baton Rouge, LA November 18-19, 2010

Core Clinical Issues in
Foster Care and Adoption
Advanced Practice Certificate
Program in Adoption and
Foster Care Competency
Baton Rouge, LA
November 18-19, 2010
Every clinician is in post
adoption practice
– Ann Hartman
Language in the Context of
Foster Care and Adoption
Members of the Foster Care/Adoption
Constellation
- Birth Parent/Family – Mothers and Fathers
extended family, grandparents
- Adopted/Foster Person
- Adoptive/Foster Parent/Family
An Overview of Some Foster
Care Issues
The implications and consequences of
abuse, neglect, and placement in foster
care on early brain development;
The importance and challenges of
establishing a child's attachment to
caregivers;
An Overview of Some Foster
Care Issues
The importance of considering a child's
changing sense of time in all aspects of
the foster care experience;
The child's response to stress, especially
as related to multiple transitions.
An Overview of Some Foster
Care Issues
Parental roles and kinship care;
Parent-child contact/frequency of visits;
An Overview of Some Foster
Care Issues
Permanency decision-making/timeliness,
Components of comprehensive
assessment and treatment of a child's
development and mental health needs.
An Overview of Some Foster
Care/Adoption Issues
Careful matching to avoid “detection”
Child’s status hidden as were parent’s
infertility issues
Birth mother excluded from knowing
where her child was placed – encouraged
to “get on with her life”
Needs of birth fathers rarely addressed
An Overview of Some Foster
Care/ Adoption Issues
Foster/Adopted parents received very little
information about the child or his/her history
Help the family “claim” the child as their own
Workers had to find the “right” family
Many workers used their “own values” to guide
this process
An Overview of Some Foster
Care/Adoption Issues
Deserving Foster/Adoptive Parents were
married couples, infertility issues,
financially stable, usually white
Foster parents, single parents, non
married couples, relatives not deemed
appropriate as adoption resources
Secrecy was key to success
An Overview of Some Foster
Care/Adoption Issues
Worker is “expert;”
Birth family is “dangerous or deviant;”
Adoptive family is “appropriate;”
Child is best served as if they were born
into the family
Historical Shifts
Myths that Continue
Paradigm shift from secrecy to openness
Foster Care/Adoption is the same as being in
a birth family
Triad members need to be protected
Everyone should move on
Win/Win/Win situation
Genetic information is not relevant
Foster/Adoptive Families and
Social Services
What happens after finalization?
Is permanency a panacea?
Most commonly cited identified need
by professionals and parents was for
qualified, adoption sensitive mental
health professionals
Adoptive Families and Social
Services
Services sought in one Illinois study were:
Individual counseling for the child (68%)
Family counseling (35%)
Individual Counseling for the parent(s) (31%)
Parent support groups (15%)
Support groups for children (10%)
26% of children were hospitalized
10% had formal placement outside of home
Families Report that Helping
Professionals:
View family as pathological, sometimes
questioning parent’s motivation in adoption;
Imply that the parent is blaming the child for
family problems when the parent raises the
need to discuss adoption as part of the
treatment;
Lack of awareness of cross racially, older
children and those adopted in sibling groups;
Families Report that Helping
Professionals:
Advise parents to avoid talking about adoption
as it will only “stir things up;”
Address child behavior problems through
behavioral methods without exploring how
these behaviors may be connected to past
deprivation, trauma or adoption;
Urge hospitalization without understanding the
underlying effects of separation for children
affected by adoption;
Families Report that Helping
Professionals:
Failed to understand the child welfare
system;
Suggest that the parents “just got a
bad one” and urge families to return the
child to the state.
Shawn’s Family
Adoptive parents (Pete and Mary Simmons, ages 37 & 39
years, married ten years) became foster parents of
Shawn when he was twelve years-old, he is now 15
years old. Shawn was born to a young teen-aged
mother who left him with her own mother, who cared for
him for eight years and then upon her death, he was
placed in the foster care system. Timothy was neglected
by grandmother who also abused drugs. Many reports
of neglect were filed with the parish. At the time of his
first placement, Timothy was described by the foster
parents as depressed, sad, and anxious – unable to
tolerate being hugged. Birth mother voluntarily
relinquished her parental rights, and the rights of birth
father (who had not been involved in Shawn’s life) were
terminated. The first foster parents were unwilling to
adopt Shawn, once he had been freed up for adoption.
The Simmons family was identified as a good match for
Timothy – they were interested in adopting a teen, Mr.
Simmon’s knew Shawn from the high school where he
taught Science and they had a good relationship.
Shawn’s Family con’t
The Simmon’s are concerned about the recent behavioral
difficulties shown by Shawn – initially he seemed to be so happy in
his new home, now he is challenging their authority, coming in late,
and possibly experimenting with alcohol and other substances.
They are particularly concerned about his recent refusal to go to
school.
Adoptive Parents’ Brief Report of Recent History:
The Simmon’s describe the adoption of Timothy as a “gift” since
they had struggled with fertility issues for ten years before
becoming his foster parents. Mr. Simmon felt that since he knew
Shawn before he came to live with them that Shawn would respond
well to their family. They felt that since his life had been so hard,
that they would not lay down too many rules for him.
Onset of Problems with Shawn:
The problems began when Shawn felt junior high and entered high
school.
Therapeutic Intervention:
Shawn’s Family con’t
Therapeutic Intervention:
Shawn was referred by a high school
guidance counselor to a therapist in the
community. The therapist had a
psychoanalytical orientation, never asked
to see the parents separately or with
Shawn, and never asked about Shawn’s
birth family. Shawn was referred to
weekly drug testing, after school help,
and after three weeks of sessions
refused to go to therapy.
Family Expectations:
What was the family’s initial experience
of adoption?
What were the parent’s dreams?
When did the dreams begin to
disintegrate?
How, specifically, did the reality differ
from the dream?
What were the consequences of adopting
this child?
Family Expectations:
How did Shawn behave in his adoptive
family?
How did Shawn’s parents originally
interpret this behavior?
How did the first professional react?
How did the parents explain Shawn’s
behavior?
What help was offered?
Context of Adoption in Therapy
When adoption comes into play
– Presenting problem
– Not presenting problem but primary issue
– Additional layer of complexity to an issue
Pitfalls for Therapists
All or nothing
Therapist’s counter-transference
The best solution is to disrupt the
adoption
Adoption work is short-term
Family-Systems Approach
Collaborative
Non-pathological model
Doesn’t foster secret/collusive
relationships- in the spirit of full and
open disclosure
Includes all triad members: birth and
adoptive parents and adopted persons
Includes the family system in the process
Behavioral Issues and Underlying
Emotional Issues:
Attachment, Separation, & Grief
Identity Issues and the Need to Search
Depression
PTSD
Core Issues of Adoption
Adoption is Different Than Birth
Adoption is a Life Long Process
The Effects of Loss
Core Issues of Adoption
The Effects of Previous Maltreatment on
Family Functioning
Issues in Attachment
Identity Issues
Mastery and Control Issues
Core Issues of Adoption
Adoption is Different Than Birth
Challenges to family functioning and child
well-being – time, biology, history
“Real” parents verses adoptive parents
Parents need to be seen as allies in the
therapeutic process
Core Issues of Adoption
Adoption is a Life Long Process
A process is not a one time event, the
adoption itself is a one time event, the
effects of living with adoption are life
long
Adolescence, marriage, child rearing,
separation are huge markers
Core Issues of Adoption
The Effects of Loss
Central to adoption process
Adoption is not possible without loss
Adopted person has loss – genetic
identity, loss of relationships with
emotionally significant objects
Adopted family has loss – infertility; loss
of continuity with biological lineage;
Birth parents have loss – surrender of
child; loss of information about the child
Core Issues of Adoption
The Effects of Loss
Loss is healed through grief
Grief is revisited over time
Developmental tasks trigger loss –
adolescence, marriage, college, childbirth
Some behavior in adopted persons viewed
as pathological may actually be
maladaptive grieving – i.e., concepts of
rejection
Core Issues of Adoption
The Effects of Previous Maltreatment
on Family Functioning
Maltreatment, trauma, prenatal exposure
to substances, deprivation, lack of
stimulation; nutritional deprivation; and
many others
PTSD trauma
Sexual abuse
Physical abuse
Core Issues of Adoption
The Effects of Previous Maltreatment on
Family Functioning
“This is my dilemma. When I think of the
abuses heaped on my child by her birth
parents, and all the struggles she had as a
result, it is hard for me not to hate them for
the harm they caused. On the other hand, if
they hadn’t hurt her, she wouldn’t have been
taken away, and she wouldn’t be my daughter.
And if it weren’t for them, she wouldn’t look
the way she does, have many of the talents
that she does. It’s complicated.” – Adopted Mom
Core Issues of Adoption
Issues in Attachment
Cycle of need and response
Infant basic needs/keep caretaker close
FAS – attachment challenges
Trust, intimacy, caretaker dependability
Core Issues of Adoption
Issues in Attachment
Dependency needs may be greater than
parent’s ability – black hole – sieve
syndrome
Attachment is on a continuum
Attachment is a two way street
Ability to attach complicated by physical
or temperamental differences
Core Issues of Adoption
Issues in Attachment
Adoptive parents with
attachment issues may believe
that such a mismatch would
never have occurred with a child
born to them.
Core Issues of Adoption
Identity Issues
Both adopted parents and adopted persons
must incorporate “being adopted” into
their sense of self.
Who am I?
Where do I come from?
How does this impact on my life?
Openness is key
Be comfortable with ambiguity
Core Issues of Adoption
Mastery and Control Issues
Basic need for competence and personal
power in one’s life
Control over one’s life; control over
creating family; control over one’s child by
birth
Control battles are common in adoptive
families as each party seeks to gain
control over their lives and situations
Core Issues of Adoption
Loss
Adopted Person
Fear ultimate
abandonment; loss
biological, genetic,
cultural, history.
Issues of holding on
and letting go
Adoptive Parent
Infertility equated
with loss of self &
immortality. Issues
of entitlement lead
to fear of loss of
child and
overprotection
Core Issues of Adoption
Loss
Birth Parent
Ruminate about lost child. Initial
loss merges with other life
events; leads to social isolation;
changes in body and self-image;
relationship losses
Core Issues of Adoption
Rejection
Adopted Person
Personalize placement
of adoption as
rejection; issues of
self-esteem; can only
be chosen if first
rejected. Anticipate
rejection; misperceive situations.
Adoptive Parent
Ostracized because of
procreation
difficulties; may
scapegoat partner;
expect rejection; may
expel adopted person
to avoid anticipated
rejection.
Core Issues of Adoption
Rejection
Birth Parent
Reject selves as irresponsible,
unworthy because they allowed
adoption; turn these feelings against
self as deserving rejection; come to
expect and causes rejection
Core Issues of Adoption
Guilt/Shame
Adopted Person
Deserving of
misfortune’
shame of being
different; may
take defensive
stance/anger.
Adoptive Parent
Shame of
infertility; may
believe
childlessness is
curse or
punishment;
religious crisis.
Core Issues of Adoption
Guilt/Shame
Birth Parent
Party to guilty secret; shame/guilt
for placing child; judged by
others; double bind; not OK to
keep child and not OK to place
them either.
Core Issues of Adoption
Grief
Adopted Person
Grief may be
overlooked in
childhood; blocked
by adult leading to
depression or
acting out; may
grieve lack of fit
in adoptive family.
Adoptive Parent
Must grieve loss of
fantasy child;
unresolved grief
may block
attachment to
adopted person;
may experience
adopted person’s
grief as rejection.
Core Issues of Adoption
Grief
Birth Parent
Grief is acceptable only for a
short period but may be delayed
10-15 years; lack rituals for
mourning; sense of shame blocks
grief work.
Core Issues of Adoption
Identity
Adopted Person
Deficits in identity
may impede
integration of
identity; may see
search for identity in
early pregnancies;
extreme behaviors in
order to create sense
of belonging.
Adoptive Parent
Experiences diminished
continuity of self; they
are not “real” parents.
Identity
Adopted Person Issues
More identities to process
Over identifying more with one family
Fantasizing, distracted in school, angry
Feeling marginalized
Lack of identity markers
Complicates independence phase
Control
Core Issues of Adoption
Identity
Birth Parent
Child is part of identity and goes on
without birth parent’s knowledge;
diminished sense of self and selfworth; may interfere with future
paternal desires.
Core Issues of Adoption
Intimacy
Adopted Person
Fear getting close
and risk re
enacting earlier
losses; concerns
over possible
incest; bonding
issues may lower
capacity for
intimacy.
Adoptive Parent
Unresolved grief
over losses may
lead to intimacy or
marital problems;
may avoid
closeness with
adopted person to
avoid loss.
Core Issues of Adoption
Intimacy
Birth Parent
Difficulties resolving issues with
other birth parent may interfere
with future relationships;
intimacy may equate with other
losses.
Core Issues of Adoption
Control
Adopted Person
Adoption alters life
course’ not party
to initial decisions;
haphazard nature
of adoption
removes cause and
effect continuum.
“Control Freak”
“Victim”
“Being Stuck”
Adoptive Parent
Adoption
experiences lead to
learned
helplessness; sense
of mastery
connected to
procreation.
Super Parent Issues
Core Issues of Adoption
Control
Birth Parent
Relinquishment seen as out of
control; interrupts drive for self
actualization.
Divided Loyalties
Adopted Person Issues
He/she does not feel free to talk
about birthparents
May want to connect with birthparents
All adopted persons search
Search and reunion and separate
functions
Parent Issues
Create loyalty issues by denying
significance of birth parent
Entitlement & Gratitude
Adopted Parent Issue
Infertility issues
Can’t assume they know their child
Have to prove they are worthy or
“perfect” parents
Existence of birthparents
Plays out in discipline, boundaries or
lack thereof
Depression
Entitlement & Gratitude
Child Issues
May not feel he/she may show
negative traits or behavior
May feel compelled to try to be
“perfect” & full of gratitude
Behavioral Issues and Underlying
Emotional Issues:
Attachment, Separation, & Grief
Identity Issues and the Need to Search
Depression
PTSD
We Never Thought it Would be
Like This! Problems Identified by
Families
Behavior problems of child
Emotional problems of child
Child-Parent relationship
Child’s relationship w/ peers
Financial problems
Child care problems
Emotional problems – parent
Job problems
Marital problems
Unresolved infertility
89%
72%
61%
48%
46%
37%
26%
25%
24%
21%
We Never Thought it Would be
Like This! Problems Identified by
Families
Common Themes
Limited Emotional Range – anger/sorrow
Marital Tensions
Sibling Issues
We Never Thought it Would be
Like This! Problems Identified by
Families
Common Themes
Isolation
Exhaustion and Hopelessness
Running on Empty
Strategies for Adoptive Parents By
Developmental Stage
Infancy (0-3)
Talk comfortably about adoption from the time
the child arrives
Start the adoption story from --when you were
born, your birth Mom . . . . Not when we
adopted you . . .
Model correct adoption language
Gather as much info about the child’s history
when the trail is fresh
Strategies for Adoptive Parents By
Developmental Stage
Pre School (3-7)
Encourage questions and answer concretely and simply.
Listen for cues about misperceptions when the child is
playing or talking with peers.
Don’t assume that telling the adoption story every once
in a while is adequate. Tell the story positively, but
realistically.
Reassure the child that they will not lose their adoptive
family
Strategies for Adoptive Parents By
Developmental Stage
School Age (8-12)
When children are not talking about adoption don’t
assume they aren’t thinking about it.
Learn to be alert for anniversary reactions – trigger
times – mother’s day, birthdays, holidays, loss.
Let children know that they can love two sets of
parents.
Don’t force discussions, look for opportunities, i.e., on
a drive in the car, anniversaries
Strategies for Adoptive Parents By
Developmental Stage
Early Adolescence (12-15)
Allow the child to exercise control whenever possible.
Be firm in limit setting.
Try to keep from responding to the child’s anger with
more anger.
Establish clear consequences for broken rules.
Maintain a sense of humor.
Strategies for Adoptive Parents By
Developmental Stage
Late Adolescence (15 - 20)
Make it clear that the child may remain home for a
time following graduation, i.e. attend college nearby.
Be alert for overreactions when relationships with peers
fail.
Talk openly about dating, intimacy, relationships.
Be aware that leaving home, even for college can feel
like abandonment all over again.
Therapeutic Techniques
Parent education - Bibliotherapy
Narrative work
Parenting that fosters attachment
Play therapy
Reframing
The Adoption story
Lifebooks
Letter Writing by parent/ by child or
teen
Journaling
Techniques continued
Genograms
Kid’s Group Parent’s Group
Mentoring for kids and parents
Guided Fantasy
Rituals
Search (inside and outside)
Facilitated Reunions