Early Family Interventions as Prevention of Escalation of Behavioral and Emotional Problems in Internationally Adopted Children
This article was first published as a chapter in the “International Perspective on Inclusive Education”, Volume 2, pp.359-374, 2012, edited by John Visser (University of Northampton, UK), Harry Daniels (University of Bath, UK), Ted Cole (University of Bath, UK), Emerald Group Publishing Limited.
In the past, fostering or adopting foreign children took the form of rescue missions and were often matters of life and death. Therefore the question of children's adjustment and their emotional problems seemed to be irrelevant. Emotional adjustment of children of international adoptions of modern time presents a challenge for educated and articulated middle-class parents and has become the focus of extensive clinical and scientific research.
Nearly all studies of adoption have documented the resilience of internationally adopted children of all ages (Tizard, 1991; Welsh, Viana, Petrill & Mathias, 2007). The majority of them do not demonstrate severe or persistent behavior and developmental problems. Nevertheless, existing research suggests that adoptees are at higher risk of developing serious mental health problems in adolescence and young adulthood and more likely to die from suicide, to be admitted for a psychiatric hospital, have drug and alcohol abuse problems then population at large (Hjern, Lindblab & Vinnerljung, 2002) and that they are overrepresented in psychiatric care facilities (Verhulst, Althaus &Versluis-den Bieman, 1990).
The data concerning adjustment of older children adopted from other countries is inconsistent. According to Verhulst, Althaus & Versluise-den Bieman (1992) "The older the age of the child at placement the greater the probability that the child will be subjected to psychosocial adversities". Other studies indicate no age-related difference in adjustment (Juffer & van IJzendoorn, 2005).
Adoptees behavioral problems are usually explained by the effects of early trauma, disturbed attachment, institutionalized behavior, and delays in cognitive development, i.e. pre-adoption vulnerabilities and deficiencies; they are primarily conceptualized within the framework of Attachment Theory. In clinical practice, transient attachment difficulties of the adoptee are often assumed to be the child's stable dysfunctional behavioral patterns-disorders of attachment. Difficulties between parents and adopted children are corrected through attachment interventions by attuning parental response to the child's behavioral cues. Attention is given to such factors as parents' sensitivity and ability to read cues and miscues, and qualities of the child' signals. (Marvin& Whelan, 2003). Such studies make an assumption that adoptive parents are "presumably sensitive caregivers" (Marvin & Whelan, 2003). The latter researchers also suggest that parents' extreme sensitivity to criticism is responsible for the lack of exploring their role in the disordered attachment". Yet rarely do researchers see adoption itself as a source of distress for older children, or consider relationship aspect of adjustment. The role of the adoptive family is viewed as one of rehabilitation.
Recommendations for prospective adoptive parents are written in a language of psychiatry to alert them about risks of compromised early development. Suggestions are given to accelerate the adoptee's access to mental health services and admissions.
For attention difficulty and depression parents are advised to use medication (Johnson, & Dole, 1999). Thus a child becomes a passive object of necessary interventions An insight in the complex process of adaptation provides reading of the stories of the former children of Kindertransport, a rescue operation of more then 10,000 Jewish children from Germany, Austria and Czechoslovakia that were brought on a brink of WWII to the Great Britain and housed with families that were willing to take them. Great majority of these children came from loving, affectionate middle class families. Their basic ability for attachment was not compromised by developmental factors and early experiences. However, their adjustment to well meaning strangers was universally difficult. Their accounts contain memories of sadness, defiance loyalty to their families and cultures, sober assessment of the character of their care-givers and episodes of explosion of repressed anger. Some of them were transferred to another care-givers (Harris & Oppenheimer, 2000).
Description of Children and Families
This presentation is a result of working with adopted children and their families in my private practice. To protect the privacy of the client, all identifying details have been removed from this publication. Consultations and, if necessary, therapy sessions for American families and their school-age adopted children from Russia were simultaneously conducted in two languages. Sixteen school-age children (5 boys and 11 girls) from 7 to 14 years of age who were adopted by white middle class parents were chosen for this chapter. Three of the families adopted siblings. The majority of these children have been in the United States from three weeks to six months when I first met them. All the children were healthy with minor medical or neurological problems or slight delay of cognitive development.
Practically all adopted parents reported decent conditions in the orphanages. Many children were well-liked by the caring staff. None of them described experiences that would be considered abuse in the orphanage except for one boy who was a target of bullying by older boys. The ages of their placement varied from birth to 2 years prior to adoption. Most of them had parents whose parental rights were terminated due to neglect (alcohol abuse was parents' common problem), some experienced physical abuse. In all children (but one) there was evidence of strong emotional ties to friends, teachers and care takers. All referred children exhibited behavioral difficulty that their parents were not able to control.
Parents often came overwhelmed and frustrated. One single adoptive mother acknowledged yelling at her adopted daughter, and of hitting her once. This difficult behavior included not listening to and not following directions, having violent temper tantrums, rage, running out of the house without paying attention to traffic. The children were angry. Some told their parents that they did not want to be in America, some refused to answer their questions, locked themselves their room and listened to Russian music. Four of the families also had own biological children. All these families reported tensions between siblings: older adopted siblings "being abusive" toward younger ones, adoptees damaged property of their newly acquired siblings. Biological children of the adoptive parents also had temper tantrums.Some of the adopted children showed symptoms of anxiety: poor night sleep, fears, checking the entrance door before going to bed.
Principles of the Intervention
My approach to presented behavioral and emotional difficulties was informed by my clinical practice. Talking to adopted children and their parents, observing family interactions and exploring relationships helped to develop key focus for the interventions. Initial goal is normalizing difficult behavior by examining in a context of adjustment to immigration and transition, associated with experience of novelty, displacement and loss and also by inquiry in pre-adoption personal history and culture that shaped the child's behavior and identity. The therapeutic work that helped to recognize, access and unburden emotions was liberating for both, parents and the adopted children and resulted in diminishing anxiety and increasing flexibility of behavior. Often most dramatic behaviors, such as rage, screaming, temper tantrums, overt hostility quickly subsided after the single or first few sessions.
The second type of intervention is a family therapy. It was needed when initial behavioral difficulties persisted. The families whose adopted children's initial difficulties persisted or even escalated usually had pre-existing vulnerabilities and therefore resolution of presenting problem requires more intensive work. One may consider the following dynamic of reinforcing the initial distress. For some alerted parents, behavior that occurred under the influence of transient yet strong emotion may be an indication of psychopathology and a call for an intervention. The adoptive parents, alerted by recommendations and warnings about the adoptees' deficiencies are especially susceptible to viewing their behavior as pathological. Behavior is labeled as symptomatic. Taking something that does not belong to a child labeled stealing, hitting the adoptive sibling is a sign of violent tendencies, not telling the truth when caught and questioned is lying, and all together symptoms of Reactive Attachment Disorder that require specific interventions. And as it often happens, chance events instead of dying out reinforced by attempts to alleviate them, children become subjects of many individual interventions which often are not effective because they are blind to the relationship nature of the behavior. Initial difficulties become rigid behavioral patterns or symptoms.
Family therapy challenges assumption of children inherent mental problems and understands human distress as a relationship dilemma and not as an intrapsychic phenomenon. Instead of focusing solely on the individual child, I addressed adoptee's distress within the paradigm of family therapy. It challenges assumption of children inherent mental problems and understands human distress as a relationship dilemma. (Minuchin, 1974; Hoffman, 1981). The adoptees difficulties were viewed as not an intrapsychic phenomenon, or a symptom of preexisting psychopathology, but as a manifestation of mutual adjustment difficulties of the adaptive family and the child. I find the systemic family therapy approach (Palazzoli, Cecchin, Prata &Boscolo, 1979; Hoffman, 1985; Cecchin, Boscolo, Hoffman, & Penn, 1987), to be especially fruitful working with adoptive families because it helps them to develop new patterns of relationships in an economical and non-invasive manner. Three aspects of this approach make it particularly effective:
1. The neutral role of the therapist does not directly challenge parents' authority. Therefore, they are more open to new ways of viewing the problem.
2. Circular questioning is a non-threatening method of gathering information and a way of introducing new ideas about human behavior. Instead of asking why someone is upset or angry, a circular type of questioning would inquire about what other family members do when this person is upset or angry. It introduces a circular causality (rather than linear) and broadens the family focus.
3. This model of family therapy addresses one of the major issues for adoptive parents: the meaning that parents attribute to the child's behavior. The family begins to recognize the relationship aspect of the adoptees difficulties. This recognition disrupts dysfunctional relational cycle and prevents the dysfunctional behavior from becoming chronic.
Adoption as Immigration
Researchers who attribute the adoptee's difficulties to early childhood trauma or attachment disorder are often likely to underestimate the enormous challenges posed by immigration and cultural assimilation for the adopted child. The fact that international adoption is for the child immigration is rarely acknowledge by specialists and the parents alike. The older the child, the deeper is his or her experience of life's disruption and the greater the magnitude of difficulties created by the new changes. The problems posed by the language barrier contribute to the child's sense of loss.
During the initial and most difficult period of adaptation, children lack the means of self-expression and communication. The inability to express their feelings often results in feelings of anger and even rage that can be easily misinterpreted as hostility. Sudden cessation of everything familiar, the profound loss of significant relationships (friends, favorite teachers, as well as social status often enjoyed among other peers) can be a major cause for experiencing sadness, loneliness, anger, feelings of loss of control, and various forms of mourning. In my clinical experience, I encountered numerous examples of behavioral manifestations of such immigration-related issues. One mother, for instance, told me with resentment, "She looks at me as if I am nobody, eats and closes the door to her room." Another parents said that their adopted teenage girl spent the Independence Day family picnic in bed. Talk about their lives before adoption gives children access to their feelings and unburdens them.
The experience of dislocation and mourning of the child should be acknowledged and validated by the new family. Such work at the early stage of adoption is essential for preventing depression and self-destructive behavior, both of which are common complications of unrecognized and unresolved grief. Because the picture of child's life that parents hold in their minds is of deprivation, neglect and abuse, they often assume that leaving the orphanage will be acknowledged positively by the child and unprepared to reactions of grief and mourning that often expressed by anger. Yet children's narratives may include themes of mastery, control, independence and friendships. By hearing their children's personal stories, parents often surprised to discover that older children feel that they lost their freedom and independence (in many orphanages teenagers had a significant degree of freedom of movement, took public transportation, could visit their friends and relatives alone, and were not always closely supervised).
One particularly illustrative case in my practice was that of a 14-year-old girl who together with her 8-year-old sister was adopted by a caring middle-class parents in the U.S. Back in Russia, when she was still with her biological parents (both of whom were alcoholics), she took care of her younger sister, fed her, and protected her from their physically abusive father. Through her repeated appeals to authorities, she and her sibling were placed to the orphanage. In the orphanage she had many friends and was a natural leader. She had a lot of freedom, could visit her friends who were not in the orphanage, and was allowed to use public transportation. Caretakers in the orphanage treated her like an adult and complained to her about the behavior of her younger sister and at times she was even asked to discipline her sister, as if she was her mother, and she would do so by yelling at her sister and at times even hitting her. She had to give her permission for adoption of both of them. When she started her new life, her past identity as a parental figure was unknown to her new parents. The contrast between her life before and after the adoption could be compared to that of a war veteran who showed exceptional bravery in combat but after discharge suddenly had to face civilian life full of unspoken rules and relational subtleties. After her adoption, she was suddenly returned into the role of a child, a passive recipient of parental care who had to relinquish her own role as a parent. Her defiant attitude, rebellious insistence on taking an hour-long walk to school alone instead of taking the bus, as well as outbursts of temper made sense for her adoptive parents and ceased to be signs of pathology when understood within the context of her past experience and relationships. Another problem is evident from this example: being adopted renders a parental role of the older sibling that included protection and disciplining unnecessary. Subsequent frustration can take different forms. Older sister ordered her younger brother not to sleep, to disobey adoptive parents, not to eat his dinner. Another older sister told her younger sibling that she is not her sister anymore. Younger sibling provoked his older brother by calling him names. He was hit by the latter in response and denounced him after that. His older brother was punished. Understanding history of relationship of adopted biological siblings renders such labels as abusive, aggressive, and manipulative meaningless. Parents will have more flexibility dealing instead with emotions: with sadness and anger.
Preservation of Memory and Prevention of Complications of Unresolved Grief
Unlike children of immigrants who leave their country with parents, adopted children carry their memories alone. In sharing them and their life stories with adoptive parents, children's life unfolds, their self-identity is clarified. Such recallections help to integrate the children's past and present and provide for a sense of continuity of experience and offers a remedy against feelings of disruption and loss of control. By emotionally responding to their children's stories adoptive parents invest emotionally in their past. They not only save children's memories from oblivion, they will be make them shared memories from now on. Studies of children trauma indicate that memory disruption and "feeling an autobiographical void" is a painful psychological experience responsible for developing depression and other complications of unresolved grief (Putnam, 1997). This aspect of therapy work is particularly time sensitive.
According to my own experience, children between the ages of 8 and 9 already do not remember many details of their pre-adoptive lives only a year or two after they are adopted. New language acquisition is one of the critical factors affecting such memory loss. Empirical facts collected in a study of more then 800 internationally adopted children reveal that they lose their native tongue faster than they acquire English. For 6 to 9 year-olds it takes several months for expressive language to lose its function (Gindis, 2005). But only much later will they possess full command of foreign language for expression of psychologically complex experiences and inner states. If the recovery of memory is not done early on, important details and circumstances that defined and shaped the children may never be known by the adoptive parents and may be lost irreversibly to the children themselves, In my own experience, described therapeutic work was liberating for both the parents and the adopted children. It diminished anxiety in both children and adults and allowed for greater flexibility and empathy and trust in their relationship. Often most dramatic behaviors, such as raging, screaming, temper tantrums, and overt hostility quickly subsided after one or a few sessions.
Cultural Aspects of Behavior
Another significant culture-related issue that helped the parents to better understand the behavior of their adopted child was shaping of some important behavior characteristics by one's culture. Certain behaviors that are considered problematic in American society are not only accepted but even valued in Russian culture. For instance, spatial proximity and physical contact are not forms of sexualized or aggressive behavior (as many parents concerned about) but part of normal communication; talking to strangers is considered acceptable; a confrontational style of conduct could be viewed as a sign of authenticity; physical aggression is not only justifiable for self-defense but also shows bravery; on the other hand, complaining to one's teacher or parent about other children is seen as cowardice or betrayal. By becoming aware of the cultural values and behavioral codes of the child's native country, parents would be less likely to pathologize such conduct and would gain the flexibility needed to change their interactional patterns. Family Therapy When dysfunctional behavior of some children persisted or even escalated, or when clashes between them and the parents became regular, the behavioral difficulties of such children were addressed through family therapy. These families had the following common characteristics:
1. The upbringing of the parents themselves was often traumatic
2. The parents understanding of normative behavior was polarized between right and wrong, bad and good. Therefore they rigidly imposed rules and always
3. corrected 'bad behavior', were unable to let go and show flexibility.
4. The parents had high and therefore easily frustrated expectations of both, adopted and biological children and often did not recognize nor respond to their emotional needs.
5. Their own children (if any) were diagnosed with various mental disorders:
6. (Attention deficit hyperactivity disorder, depression). Various family members (often including the parents themselves) were on prescribed psychotropic medications.
7. The conflicts in these families were never resolved because disagreement and overt expression of strong emotions was perceived as a threat and was not allowed.
In families described above single or chance events (behaviors) are usually interpreted as intentional, malevolent or pathological. Instead of dying out or being let go they are reinforced by a parent's reaction to them, usually by a punishment, by imposing rules or by initiating treatment. The adoptive parents, alerted by recommendations and warnings about adoptees deficiencies are especially susceptible to viewing their behavior as pathological. The child becomes a subject of many individual interventions that are not effective because they are blind to the relationship nature of the behavior. The roots of the behavior are not addressed; and therefore initial difficulties persist and become rigid behavioral patterns or symptoms. Often medication is prescribed to correct them. I will illustrate how I addressed such issues in therapy with one particular family. A ten-year-old girl, adopted by parents who had two biological children - a sixteen-year-old daughter and an eight-year-old son - was referred a year after her adoption with the following complaints: impulsive behavior, lack of respect for privacy, disloyalty, lying, hitting other children, and taking things that belong to her adoptive siblings. The adopted girl reacted to attempts to correct her behavior (time-outs, taking away computer etc.) by screaming, wailing, and hitting herself. Briefly discussing with me a prospect of therapy over the phone, her mother expressed hopelessness about her family ever again being happy. At the first session the father barely talked and did not always pay attention to the conversation in the room. The youngest boy, as if habitually, was trying to occupy his mother's lap, while the oldest sister kept looking at her mother to see the expression of her face. Therapy with this family was based on a systemic family therapy approach in which an array of therapeutic tools was applied: circular questions (therapeutic technique based on the assumption that behavior or expression of emotion of the family member cannot be understood in isolation, but must be seen in their larger context in connection to the behavior of another family member in a circular manner rather then in the usual lineal way. Instead of asking why is somebody in distress, circular question would inquire when somebody show distress and what other people do when this happens); tracking behavior patterns; identifying sequences of events; finding "openings" - important and revealing facts whose significance is originally unrecognized; exploring and challenging family beliefs and reframing the problematic behavior; sharing ideas and giving feedback to the family as well as pointing out successes and positive changes. In the course of therapeutic work with this family, the following developments could be distinguished as critical turning points towards positive change:
1. Redefining the child's problematic behavior. Thus, such behavior as entering the room of an adoptive sibling without permission was no longer labeled as "violation of privacy," the act of taking another child's toy was no longer perceived as "stealing", she did not care about her own belonging as well, while unwillingness of the child to tell on herself was not a mere "lying" but a normal response of a healthy ego.
2. Challenging beliefs within the family, in particular the notion that only the adoptee is the source of serious problems and the sole reason for dysfunctional family dynamics. The idea that other children experienced problems similar to their adopted sister was introduced and specific instances of such conduct - from temper tantrums, regular outbursts of anger, and teasing to jealousy feats - were pointed out. The oldest daughter and the father took medication for depression and ADHD.
3. Revealing the sequence of events that explained the oldest daughter's tantrums and rage and thus helping to understand the meaning these recurrent violent outbursts of anger and stopping them. One example was the subtle manner in which the youngest brother was able to gain his mother's attention at that very moment when the daughter wanted to talk to her mother privately. He usually entered the room and jumped to his mom's lap. The mother would not protest and turn her attention to him. The daughter would begin screaming and hitting her sibling only to be punished for such 'violent' outbursts by being sent to her room.
4. Examining the development of the mother-son dyad revealed that it was based on the need on the part of the mother to offer extra maternal care and comfort to her son due to gastroenterological discomforts he had in infancy. His close ties with the mother were threaten with change; and he responded by not letting her to take care of the adopted daughter when she was sick.
5. Exploring the mother's statement that she - unlike her own parents - wants her children to be happy and to be able to offer them comfort in difficult times - a revealing "opening" that led me to investigate her own upbringing. As it turned out, her own parents were never home, and she was brought up by her grandmother. Memories of her childhood were painful to her since she felt unloved as a child. Once she started a family of her own, she took upon herself the task of becoming an ideal mother and creating a happy family. To safeguard against children's difficulties, she signed them up for many after-school activities and groups for personal development. She was constantly involved in self-imposed projects and was equally demanding of her husband. Any issues and problems within the family - fights between siblings, their moodiness or bad grades in school, or arguments with her husband - were all acutely felt and considered by her to be personal failures. Since her myth of a "happy family" was unattainable, she experienced chronic anxiety and disappointment with herself, her husband and her children.
6. Exploring the father's behavior and parents' relationship. At home he was often tired and angry and did not comply with his wife's demands. He blamed himself and admired her efforts to run the family. Since his disagreement was unacceptable to his wife, he would get angry and shout, but was relieved that a prescribed anti-depressant medication controlled his violent outbursts.
These interventions allowed the identification of the sequences of dysfunctional behavior instead of labeling it as "personal problem" or "psychiatric symptom." and thus enabled a break in the pathological cycle. This discovery within the family led to new-found sense of relief and allowed for tolerance to differences and disagreements. Rigid expectations about children's behavior and development were replaced with increased flexibility. Children's complex emotions were recognized. Mother saw a connection between her personal history and her maternal behavior. The parents began to better understand their children's complex emotions and learned how to acknowledge them. The children, in turn, found access to their frustrations and unburdened them during therapy, which created an impulse to the development of self-understanding and confidence.
Challenging rigid expectations about children's normative behavior and development, I helped the family accept the idea that positive change requires time. While praising the mother for her caring efforts and endurance, I helped her see the connection between her personal childhood history and her current maternal behavior. In a course of 12 family sessions the behavior of all the children improved, the parents acknowledged that the original problems of the adoptee were resolved. Parents were also able to see that their own relationship issues hindered further progress and have to be addressed. As a result, once the behavioral issues of their children improved, they decided to terminate family therapy and seek marital counseling.
A single case of therapy failure can also offer insight into the development of chronic behavior and emotional problems in adopted children. Such was the case with one family that withdrew from therapy. The family, which adopted a 9-year-old girl, belonged to a rural religious community. The biological mother's parental rights were terminated due to mental illness and inability to take care of her daughter. The family came to me one month after adopting the child who deeply missed her mother and talked about her a lot during our meetings. The adoptive parents came with a list of therapy goals and expectations that included the following: helping the child understand that her stay in the U.S. is permanent and that she must become part of the family; teach her how to play with children of her age, to share with siblings, and maintain a positive attitude as well as to help her understand the importance of school and make her feel good about her progress. The above goal was echoed in their complaints such as poor attention span, and trouble sitting still and follow directions during the daily two-hour English lessons with the girl's adoptive mother. Parents began to worry when she told them that she wants to return to Russia. They were relentless in their demands and expectations of quick improvements. Their inflexibility was fed in part by a strong need to succeed for a family that was part of a closely-knit community where everybody was watching them. The parents' frustration was never expressed directly but through increasing efforts to better the girl's behavior. They were reluctant to ease the pressure and give her more time to adjust. The girl's growing anger was interpreted as stubbornness; the act of not sharing with her adoptive siblings was seen as typical of behavior of an only child. While her missing her mother was initially acknowledged, the parents were losing patience and felt that she already should let go. The girl grew more defiant and did not apply the required effort to learn English. She pushed the adoptive mother and made a gesture as if she was cutting her wrists. Following this episode she was brought to a psychiatrist who has been treating her fourteen-year-old adoptive sister for ADHD. The girl was also diagnosed with ADHD and was prescribed psycho-stimulants. Her parents did not accept any suggestions hinting at their impatience, inflexibility or problems in anybody else' behavior, and they were reluctant to recognize her grief. The father never showed up in my office, and after the fourth meeting the family withdrew from treatment. Six years later, I received a phone call from the adoptive mother and learned that the girl was subsequently diagnosed with Oppositional Defiant Disorder and Bi-polar Disorder due to her violent and suicidal behavior. She took medication and was hospitalized. She was then living with the neighbors with whom her behavior improved. The mother asked for my agreement to be the girl's therapist, but never called to follow up and schedule an appointment. The onset of the cycle of problematic behavior was triggered by the lack of recognition and acceptance of the child's distress and the depth of her grief that led to an intolerance to her dysfunctional behavior. Labeling her behavior as "pathological" and quickly moving to eradicate it through aggressive psychiatric treatment helped to maintain the once-triggered cycle through a dynamic of escalation and treatment.
Conclusion The results of my work with the adoptive families demonstrate that early family-centered interventions lead to behavioral improvements, prevent deterioration of child's behavior, and build a foundation for a lasting relationship. In this work to help the adoptive families, the issue of attachment of the adoptee to his/her new family was not approached directly. Attachment was viewed as a result of development of trust and mutual understanding. Successful resolution of behavioral and emotional difficulties at the early stages of adoption forms the basis for lasting attachment and will help to prevent development of chronic mental problems in children. The main principles of such intervention are as follows:
The form of intervention is a dialogue between all family members. It facilitates safe self-expression and eases overwhelming emotions.
Child's behavior is understood within a framework of adjustment to a transition, associated with experience of novelty and loss.
Changes that effect and cause tensions within the existing family system (such as adoptive siblings) are addressed.
Certain problematic behaviors and their former adaptive function are reframed and thus normalized within a context of the child's culture.
In the process of sharing his or her story the child's life unfolds, integrating the past and the present, facilitating continuity of memory and preventing disruption of identity and reactions of complicated grief.
The adoptive family's preexisting dysfunctional relationship patterns are addressed trough family therapy.
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