Friday, May 23, 2014

What's in a Name?

One of the highlights of becoming a parent is naming the child.  People, both men and women, start at a very young age, about the time they get a new pet or learn where babies come from, thinking about names they might give their children.  And when expecting and prospective parents approach the event, naming the child usually becomes an exciting and serious part of the preparation.  Names are important, signaling belonging and identity, and having lifelong impact and meaning.

However, this ritual part of parenting is complicated when the child is adopted either by strangers or family, in the case of child welfare, international, and private adoptions or step-parent and grandparent adoptions.  When adoptive parents are identified before the birth they are often allowed by the biological parents to choose the baby's name or participate in naming the child.  That is not the case when the named child is adopted after birth, except in some situations, both foreign and domestic when the infant has not been named at all.  Generally, the older adopted child has a name and a birth certificate identifying the names of the child and the biological parents.

That means, whether the child was intended for adoptive placement or the court has determined that the child will be adopted, the biological parents and not the adoptive parents have chosen the child's name.  Like so much else in the adoption process this is sometimes a source of conflict and sadness.  The biological parent, whether intending to place the child for adoption or later having parental rights terminated due to abuse and neglect, took the first important step of claiming the child by its name.  The adoptive parent(s) who wants to make this child his/her own, misses this monumental privilege.

Sometimes adoptive parents try to take this privilege back for themselves by re-naming the child.  This can have detrimental and sometimes devastating consequences for their relationship with the child and the child's own development and mental health.  Last names are a little less tricky.  Adding a last name, as in John Doe Smith, says to the child and the world that John Doe belongs to the Smith clan.  But by changing John Doe to George Smith, the adoptive parents are sending a strong message that they wanted George, whoever "George" is, and "John" is simply not acceptable.  How John becomes George after identifying himself as John is cause for years of identify confusion.  You cannot make John and his biology go away by calling him George.  That just adds to the trauma.

It didn't seem to bother President Gerald Rudolph Ford, Jr. who was re-named after his adoptive stepfather from Leslie Lynch King, Jr. after his biological father.  But that was in the early 1900's before we understood much about identify development in children.  Through the 1950's the shame of unwed pregnancy led to "illegitimate" births (as if a child is not real) and secret adoptions with closed records.  Reaction to the stigma continues to this day with the state re-issuing new birth certificates replacing the biological parents names with the adoptive parents names pretending the original event did not happen.  How is that supposed to make an adopted person feel?  California and other states are beginning to make adoption records and original birth certificates available to adopted people.

To be sure, some names are quite unique and require explanation and pronunciation.  One biological mother named her girls Chevy and Corvette.  Another Johnny Walker.  There's a story there.  Early last century Beverly, Gay, and Adolphe were acceptable boys names.  These days North West seems to work.  Hollywood stars used to change their names to hide who they were.  Now we can celebrate the work of Chiwetel Ejiofor and Charlize Theron and learn to pronounce their names.  When a Chinese girl named Chan-juan is renamed Mary Rose she loses her country and her culture, graceful moon, but is expected to live up to her new identity.  Something says, "You are not who you are supposed to be."  Adoption is about addition, not subtraction.  Gerry Ford's legal name could easily have been Leslie Gerald Rudolph Lynch King Ford, Jr.  It wouldn't fit on a bumper sticker, but it would fit on a legal document.  No need for a new birth certificate.  His story is part of history.

In the teenage years, youth begin to explore their identities.  John becomes Johnny becomes Jack becomes J.R.  Or, a youth begins to live her/his gender identity and asks to be called Chelsea instead of Charles.  Generally, we do not get to pick our names.  Parents have that responsibility.  Adoptive parents have the additional responsibility of managing their own grief and loss over not giving birth and having naming rights.  They also have the responsibility of celebrating their chosen child for who they are and not the "ideal" child they had in mind.  That includes accepting from whom they were born and for whom they were named.  There is no shame in making another person's child your own.


Monday, April 7, 2014

Paying Attention to What Hurts

A four year old, asked why her drug addicted mother left her at the hospital, says, "I think I cried too much."  A fourteen year old, also born exposed to methamphetamine, says, "I think it was because I was a boy."  That is the case for eight girls left behind by a mother who fled to Mexico with a son. To the last one, the adopted children with whom I work feel there is something deeply wrong with them.  And their sometimes strange and dangerous behaviors often have their parents believing it is true.

Attachment and trauma-informed care asks us to think about it in a different way.  These young survivors of physical, emotional, and sexual abuse; neglect, abandonment, and multiple placements have developed some interesting coping skills to deal with painful emotions and fear of closeness.  Their parents are also coping with these difficult behaviors; lying, stealing, aggression, manipulation, defiance, tantrums, and control battles.  The parents and children are both saying, "Make it stop!"

In her article for the March/April 2014 edition of Social Work Today, "Mindfulness, Women, and Child Abuse: Turning Toward What's Difficult", Char Wilkins, LCSW, faculty member at the University of California San Diego Center for Mindfulness writes about techniques for adults.  It dovetails nicely with the principles of Acceptance and Commitment Therapy promoted by Russ Harris, M.D.  The focus is on accepting and being present with unwanted feelings without resistance.

It is very difficult for parents to watch their children suffer.  In my experience it is even more difficult for parents to experience sadness, anxiety, and shame with their children.  Like their children, parents (like all people) avoid, deny, and distance themselves from troublesome thoughts, feelings, and sensations.  Yet these are the fears that drive the unwanted behaviors.  If a parent cannot tolerate these feelings, what is a child to do on her own?  Parent and child are running, from each other.

Yet, while it is not the entire treatment, focus on these unpleasant feelings can make them less powerful.  Without pushing or pulling, they can be regulated.  "Fear is here," as Wilkins writes.  As in Post Traumatic Stress Disorder it turns on the fight/flight response and releases the stress hormones cortisol and adrenaline.  But with practice, the chemicals dissipate, the extreme reactions slow, the brain's emotional amygdala is quieted and the thinking cortex begins to make decisions toward self care.  The keys here are presence and silence.  I have participated and watched as parents have demonstrated with their breathing, posture, and touch that they can be trusted with their child's heavy burdens.  The bodies relax, the expressions soften, safety returns, and the relationship grows stronger.

Thursday, March 27, 2014

When Adoption Fails

We call it a "Forever Family". Adoption is a permanent plan for parenting a child.  But what if the plan is not...permanent?  What happens when adoption fails?  It's a difficult subject and there is little research.  It is painful when parents cannot or do not want to continue their commitment to a child.  The child feels rejected and lost.  The parents feel guilt and shame.  But how often does it happen?

If you consider adoption to be a legal arrangement whereby an adult agrees to take on the rights and responsibilities of parenting a specific child, it's like a one-sided marriage.  Children cannot consent to be adopted but at 12 they can legally veto the idea.  Despite the law, a child does not have the cognitive capacity to consent to adoption anymore than he or she can make a mature decision about marriage.  That does not mean, however, that a child cannot make his or her feelings known.

Strictly speaking, adoptions do not generally fail.  When an adoptive placement fails before legal finalization, it's called disruption.  The Adoption and Foster Care Analysis and Reporting System surveys completed by state adoption workers and compiled by the U.S. Department of Human Services show 10-25% of adoptive placements failed before finalization between the 1980's and 2000's. When a finalized adoption is legally reversed, it's called dissolution.  The AFCARS show .5-3% of finalized adoptions are nullified. This number is small because courts do not dissolve a legal adoption unless adoption workers can identify another family to adopt the child.  The AFCARS indicate if a child has been previously adopted.  The dissolution is like a divorce.

Examples of adoptive placements that failed before finalization include a military family placed with a teenager; empty nesters placed with a severely neglected nine year old; and a couple who asked the boy be removed after nearly a year in placement. Examples of children placed out of the adoptive home include a foreign born girl adopted after several failed placements; a teenager adopted as a small child; and two teenagers who became aggressive or abusive with siblings. 

More often, and here the research is lacking, the legal adoption is not dissolved but parents or child welfare workers place the child outside the home, with relatives, in foster homes, or group homes.  Parents may place their children if they cannot safely maintain or do not want to parent the child.  Child welfare workers may place the child if abuse or neglect is happening in the adoptive home.  Sometimes adopted children re-enter the child welfare system only to be adopted again.

Why does adoption fail before or after finalization?  The research indicates that adoptive families and children are inadequately assessed and prepared for adoption.  Adoptive parent assessments or home studies may identify the issues that mostly commonly interfere with a successful adoption but without a specific plan to address them or a decision to prevent an adoption.  Those issues are unresolved infertility and personality traits that make it difficult for an adoptive parent to commit to a child or to tolerate trauma-related behaviors.  Despite the requirement for full disclosure adoptive social histories or tellings often have missing information about the child's early trauma exposure that can impact their ability to attach to new parents.  The research also shows a lack of sufficient post-adoption support.  Just as impactfull is the willingness of adoptive families to seek and use services. 

 The military family sought support parenting a 14-year-old girl abandoned by her parents and left in foster care with multiple placements.  However, the girl began to act out and make allegations against the parents, which is common for children who fear commitment. The father's security clearance was red-flagged during the investigation, and the family was not able or willing to risk their livelihood to care for the child.  The girl went to a group home.  The empty nesters had successfully raised three children in a conservative religious home.  But their beliefs could not tolerate or help a boy who lied and stole due to severe early neglect.  They could not suspend their right/wrong black and white thinking to empathize and supervise the boy who went into a group home.  For almost a year the last couple celebrated holidays and birthdays, decorated his room, and signed him up for little league.  But when the boy began to test their commitment by rejecting their direction and care, they saw it as disrespectful.  Each parent had substantial unresolved child trauma and took it personally.  The boy returned to foster care and subsequently lost another rushed adoptive placement before it even began.

The single mother was the third adoptive placement for a three year old brought from a Central Asian country to the United States by a foreign adoption agency.  As her 12th birthday approached the connection to her mother began to fray.  She ran away from home, tore up her room, broke a window, and threatened to kill everybody in the home.  Her mother sought help from all sources until she had to ask a judge to take the girl into custody and place her in a group home for everyone's safety.  An older couple was completely committed to an intelligent boy they raised since his mother left him at three.  Nobody believed them when they said he felt no remorse and could look them in the eye and lie.  He charmed or conned professionals into believing his parents were too harsh until he took up a knife and pushed past his mother in their home.  They visit him in a group home.  Two other couples who faced infertility but had big dreams for big families took in one then a second traumatized child.  When the first one began to attack the second one because of neglect-based trauma, they sent the first child to a county-funded group home.  One couple tried to participate in treatment but were not included and decided to bring the boy home anyway.  The second couple refused to participate in treatment and the group home placement became their preferred solution.

The information about why adoptions fail also tells us what helps them stick or succeed.  Parents who have processed their own traumatic experiences and are aware of their triggers are better able to tolerate and respond effectively to a child's trauma-based behaviors.  Parents who have grieved their infertility and buried their ideal child can be open to a different path with a unique child born in another family.  Adoption workers will dig deeper for more information and not spare potential adoptive parents any of the unpleasant details so the child does not experience another rejection.  Intelligent effective people will accept help and support for the lifelong adventure that is adoption. This also applies to private planned adoptions in which birth parents place their child for adoption with a waiting family at birth and maintain contact.  Adoption involves loss; for the child, for the birth parents, and for the adoptive parents.  That fact requires attention for all adoption to succeed.






 

Monday, March 10, 2014

Using Emotion Focused Therapy with Couples

     Couples coming for counseling are often in a state of crisis.  The issues can be many: careers, communication, money, parenting, sex, infidelity, substance abuse, trust.  Some couples have never attempted therapy, choosing to work on their own or with the support of family and friends.  Others have tried therapy a number of times but have not found satisfaction.  Many couples see counseling as a last try at saving the relationship having already considered separating.  Some, however, use therapy to determine whether the pairing will take off or how to improve a stalled relationship.

     One intervention that works well and quickly is Emotion Focused Therapy based on the book by Dr. Sue Johnson, Hold Me Tight: Seven Conversations for a Lifetime of Love (Johnson, 2012).  It is an easy and engaging read, great for any couple, and a good starting point for counseling.  It dovetails beautifully with attachment based therapy which focuses on relationship instead of behavior and the lasting effects of childhood experiences, particularly early trauma.  Combined with Attachment Communication Training outlined by Michael Orlans and Terry Levy in Healing Parents: Helping Wounded Children Learn to Trust and Love (CWLA, 2006) it provides practical skills and tools.

     For one, EFT gives people permission not to be perfect.  It actually assumes that each of us has a few leftover wounds from childhood that sometimes haunt us in the present.  Second, Emotion Focused Therapy gives people permission to ask for help from their partner in healing these old wounds.  No man, or woman, is an island, and the expectation of a relationship is that the pair can develop a "Dance of Attunement" that meets the needs of each individual (Parenting from the Inside Out by Daniel Siegel, M.D. and Mary Hartzell, M.Ed. [Penguin, 2003]). Third, EFT respects the sovereignty of the individual in the give and take of a relationship but also holds each accountable.

     Johnson identifies attachment needs or rights as: love, respect, safety, attention, value, and validation and alternately attachment wounds as feeling: hurt, abandoned, afraid, unnoticed, devalued, and demeaned.    EFT focuses on accessibility, responsiveness, and engagement.  The seven conversations or steps are: recognizing the pattern, uncovering attachment wounds, revisiting past disconnections, engaging and connecting, apologizing and forgiving, bonding through sex and touch, and keeping love alive.  Effective communication steps including sharing, listening, restating, and feedback go a long way in helping couples reconnect.  Humor and humility really help, too.

     For example, Mark and Jane came complaining of constant arguments over his work schedule and her shopping.  Mark grew up with an overbearing mother who believed he married "beneath him".  Jane was raised by socialites who kept up appearances.  As Mark spent more time at work, Jane developed a serious drinking problem and eating disorder.  Her parents blamed Mark.  His mother encouraged him to dump her.  Underneath this attack-attack pattern was real love and commitment.  Mark and Jane learned to carve out space for their relationship and protect it from outside attack.  They started routinely communicating much deeper feelings and intimacy and teamwork returned.

     Karen and Tim had lived together for more than a year.  They enjoyed each other's company immensely.  Karen loved Tim's friends and his unique career.  Tim loved Karen's daughter and her sense of humor.  It was a really comfortable relationship, but Karen wanted more.  The relationship with her daughter's father never took off, and she wanted to settle down.  Tim had suffered a painful divorce and was still bruised.  Their pattern was attack-withdrawal.  Karen picked at Tim over chores and bills but what she really wanted was marriage.  Tim had said "someday" to marriage several times but then tried to avoid any further conversations.  When Karen was able to ask for what she really needed, and Tim felt safe enough to say no, they were able to stay friends but not partners.

     Emotion Focused Therapy helps couples move toward deeper more meaningful conversations.  One thing that couples like the best is the ability to give themselves a break, to be human, to make mistakes with each other, to catch them, to correct them, and to keep working on relationship.

Monday, March 3, 2014

Parents' Points of View


Jennifer refuses to take the stage with her classmates in Chula Vista for Kindergarten graduation. She clings to her parents. Jennifer’s mother planned a big family party. Alice is so angry she sends Jennifer to her room as soon as they get home. 

“My hands were tied at that moment, that’s all I could think to do,” says Alice.

Jennifer’s father Albert says, “It was frustrating.  It would turn a simple situation into a circus.”

            Sally, 13, leaves the house late at night. Her parents, Gary and Deidre, of Clairemont, are afraid. Sally is failing some classes. Her I-Pod and laptop are broken in a tussle with Gary.

            “It was very negative.  We didn’t have much fun together.  I think every day was stressful,” says Deidre.

            It is easy to call it a “stage”, until it becomes disruptive or unsafe. These parents began answering four questions.

WHAT DOES THE BEHAVIOR SAY?

Sometimes parents have to be detectives with their children.

“We noticed there was a fear inside of her for new things and for being away from her parents,” says Albert.

Sending Jennifer to her room alone made it worse. 

 “I realized she was born with these issues,” says Alice, “And that helped me understand her better, putting myself in her shoes.”

Sally’s parents could not set limits and defined her as the problem.

Gary says, “We weren’t able to correct behavior and what we needed to have happen was lost in this big emotional mess.”

WHAT DOES THE BEHAVIOR MEAN TO ME?

            Parents check in with themselves.  Alice is able to see the graduation as her own agenda.

            “We had expectations for our other children, and we needed to learn to treat her as an individual,” says Albert of Jennifer.

Gary was left to raise himself and fears his home falling apart. 

“I felt like we were losing control. We had this girl with lots of potential, and we were spirally, pretty scary actually.”

WHAT ARE MY EXPECATIONS?

            Parents have a lot of expectations. For their children.  In their heads. They come out as commands, sometimes in anger, most times in constant reminders that teach children not to listen.

            “We had them but we didn’t spell them out, and especially having family meetings.  And having consequences that match, that are relevant, that teach and don’t go overboard,” says Deidre.        

Greg and Deidre learned their teenager needed to have a say, to be heard.

Jennifer needed a few minutes with Alice after school, then she could move on to her list of chores.

“I’ve been trying to avoid saying no, I’ve been trying to say yes, but not now,” says Alice.

WHAT IS MY ULTIMATE GOAL?

            Parents say, “Just once, let the thing I’m asking be done without debate.”  Yes, we take parenting a day at a time, but it also helps to take the long view. Children do a lot of silly messy unacceptable things. They need to make mistakes to learn.   

They need parents who are in control… of themselves.  When you “lose it” with your kid, you’ve lost your power. 

            “The biggest thing for me was dropping the rope and not extending the argument beyond her understanding and my ability,” says Gary.

“We also learned that we didn’t have to consequence right then.  We could come back when everyone was calm and logical,” says Deidre.

Alice and Albert want a confident daughter.  Baby steps.  Jennifer no longer hides at the pizza place.

 “My mother took the girls to Chuck E. Cheese and she’s hugging Chuck E. and she’s not afraid of him and she’s smiling and having fun. She was able to stand up in front of the whole class and sing and dance,” says Albert, and play soccer, too, after a kiss from Mom.

Fix your mistakes in front of your child.  Focusing on relationship before behavior lays a foundation for the future.

You Can’t Fly a Kite Without a String

The string between parent and child is the relationship.  Parents make this connection through their commitment and daily care.  A parent lets out more string to allow for growth, pulls back to protect from danger.  Like the roots of a plant, it takes nurturing to grow.  It takes play.

·         Make silly faces with young children. Plan a coffee date or workout with an older child.

·         Patty cake and massage for young children. A back rub or manicure for an older child.

·         Read to young children. Tell old family stories or childhood memories to an older child.

·         Play a board game without rules with a young child. Do crafts or cook with an older child.

For best results, focus on eye contact, touch, being with, not teaching. Minutes matter. And, it’s free.

Facilitating Developmental Attachment

Daniel A. Hughes, Ph.D., 2004, Rowman and Littlefield Publishers, Inc.

Parenting from the Inside Out

Daniel J. Siegel, M.D. and Mary Hartzell, M.Ed., 2004, Jeremy P. Tarcher/Penquin

The Five Love Languages of Children

Gary Chapman, Ph.D. and Ross Campbell, M.D., 2005, Northfield Publishing

www.loveandlogic.com 800-338-4065

Monday, February 24, 2014

Trauma's Long Term Effects


Tiffany was adopted at the age of four after being removed from a mother with schizophrenia and a father with substance abuse.  She had been exposed to emotional abuse and neglect.  She lived in several foster homes including two failed adoptive placements.  At the age of nine, Tiffany was still suffering stress that had developed into Chrone’s Disease, a condition in which stress begins to attack the organs and appears as gastrointestinal pain.  As in adults, stress in children often appears as somatic symptoms like headaches and stomach aches.  Tiffany was working with a therapist to use biofeedback techniques to reduce her pain. Sensors and a monitor help patients become aware of their respiration, pulse rate, and skin temperature, and to practice relaxation techniques to reduce them.    Hooked up to this equipment for the first time, watching her favorite cartoons on a normal day in the home in which she has had great success, five years after her adoption finalized, the equipment showed Tiffany’s stress level alarmingly high.  A combination of therapy, relaxation, exercise, diet, and medication would get it under control. 
     This is an example of the life-long impact of trauma.  Traumatic events have physiological effects on the brain and body.  In the face of a stressful event, the body releases the  hormones cortisol and adrenaline.  They are very helpful in preparing the body for performance in exciting experiences or defending against threat.  However, repeated exposure to trauma causes the body to release these hormones even when they are not needed, and these chemicals stay in the brain, bloodstream, and body causing long term damage.  Survivors of trauma may then attempt to cope with this stress in ways that cause additional damage.

    Trauma is an event or set of circumstances that overwhelms an individual's ability to cope.  It can include abuse, neglect, abandonment, death, divorce, separation, violence, war, natural disaster, crime, mental illness, substance abuse, incarceration, and serious medical illness or procedures.  Research shows 61% of men and 51% of women report experiencing trauma, a majority more than one event as a child or adult.  Those reporting trauma include; 90% of mental health clients, 97% of homeless women, 66% of substance abuse clients, and 77% of male veterans.  In addition to mental illness and substance abuse, trauma can lead to eating disorders, smoking, self harm, sexual promiscuity, heart disease, liver disease, cancer, and early death.

   My experience working with children who have been abused and neglected is that this high level of stress is just under the surface and drives many of the maladaptive behaviors that interfere with family life.  Almost everything from food hoarding and stealing to aggression and poor self care can be traced back to early experiences of trauma.  And because the earliest trauma happens in the context of what is supposed to be a nurturing relationship with a primary caregiver, the resulting stress affects relationships with parents, siblings, caregivers, teachers, and other adults.  To trust an adult, to be close, to receive nurturing care is highly stressful for these children, youth, and adults.  Their coping, then, is driven by the stress including efforts to avoid intimacy.

   Trauma-informed care and parenting then requires an acceptance and appreciation of this trauma including the person's efforts to avoid more pain and suffering and to manage stress that never leaves.  The goal of the parent, caregiver, or professional is to provide a safe environment in which the survivor of trauma can process what has happened to them, develop safe and healthy coping skills, and reconnect in relationships.  Since trauma is so prevalent and universal, it is important for helpers to address our own trauma histories,  to prepare to be triggered, and to practice self care.

Monday, February 17, 2014

Adult Attachment

      The child attachment styles become adult attachment styles.  Mary Main at the University of California San Francisco developed a detailed interview that reveals the attachment styles of adults.  The AAI is a sophisticated protocol meant to be delivered by trained professionals.  However, the basic questions can be found in Daniel Siegel’s book, Parenting from the Inside Out.  Adult attachment is the style in which people relate to others including children.  Main found that the adult attachment style is 75% predictive of the kind of attachment the parent is able to help a child develop to them without the child’s presence.  An awareness of our own attachment style is helpful in parenting traumatized children with compromised attachment.  It determines our ability to bring them close to us, helping them become more securely attached.  Like child attachment styles, Main describes a continuum of four fairly fixed adult attachment styles; secure, dismissive, preoccupied, and disorganized.  The adult with a secure attachment style did not necessarily have a perfect childhood.  Rather, the person is able to recall and process both positive and negative experiences in a coherent way he or she has incorporated into his or her life story.  The person with a dismissing attachment style may not be able to recall details of their childhood experiences and often assign meanings and emotions to the content that are not coherent.  Preoccupied attachment means the adult is “preoccupied” with his or her own painful childhood and the wounds are very real and present in everyday life.  The person with a disorganized attachment style has no particular pattern and all their relationships suffer. 

            Generally, consistent, caring, committed parenting creates secure attachment in children who become adults with secure attachment styles.  Inconsistent parenting creates anxious attachment in children who may grow up to be adults with preoccupied attachment styles.  Absent or rejecting parents create children with avoidant attachment styles who may be dismissive as adults.  Punitive parenting creates disorganized attachment in children and adults.  The adult attachment style is predictive of parenting style.  The secure adult does not take the child’s behavior personally and can provide a safe base for a child to develop trust.  The dismissive parent is not necessarily one who pushes the child away, but one who cannot attune to the child’s pain, in part, because they cannot acknowledge their own.  The preoccupied parent takes the child’s behavior personally.  The disorganized parent is unpredictable and does not contribute to secure attachment nor to moving a traumatized child toward it.

            Now, you say, “But my childhood’s over and I can’t go back and redo it.”  It kind of feels hopeless especially if our own attachment style so influences our parenting.  What this requires, then, is an exploration of our childhood and its effects on our relationships and functioning.  This process of looking at our past and bringing up old experiences and feelings can be difficult and painful.  Each of us has buttons, things that bug us or trigger a strong emotional reaction.


The adoptive mother of Donald and Harold described a sometimes angry but loving father and a nurturing but sometimes permissive mother.  Her parents live with her and she has several siblings.  She can describe the ups and downs of her life, the achievements and losses, with both pride and sorrow.  Her story makes sense.  So, when Donald refused chores and Harold had tantrums, she was stressed, but she called in her support system, reached out for help, and kept her sense of humor.  Her secure attachment allowed her to stay up nights with fighting, screaming boys, seeing it as a sign of their trauma and staying close and connected until they began to feel safe with her.

 In contrast, the mother of a ten year old boy, adopted weeks after birth, hid in the bathroom or drove away from the home when her son came knocking and demanding that she help him with chores or make him food.  This anxious child grew more anxious, and his mother could not understand why his behavior continued.  She is a loving mother.  She described an authoritarian father who demanded perfection in her chores.  Asked what she did when her father checked on her work she said, “I kept my head low.  I did my chores and stayed out of his sight.”  So, when her boy wanted her attention, she did not hear her son, she heard her father.  And, when she was able to acknowledge that old trigger, she was able to train herself to stay with her son in his distress, to play with him even if she wanted to escape his fear of losing her and her approval. 

One adoptive couple, about to parent an anxious boy and an avoidant girl, came for a first appointment.  The mother-to-be had questions about furnishing the bedrooms.  When asked about her childhood, she said, “It was happy.  I don’t remember much before the age of six.  It was happy.”  Her husband looked at her, puzzled, “Honey, don’t you remember that you got diabetes early and spent a lot of time in the hospital?  And, that your dad was kind of mean.”  “Oh, I forgot that,” she answered.  The father-to-be, on the other hand, described a difficult childhood with alcoholic parents who almost divorced when he was 12 then sobered up for his adolescence.  He had been to some therapy and had made peace with his parents.  He had developed “earned security”.  However, the mother’s dismissive attachment style led the family to put counseling on the back burner for their two new children going through another traumatic move.  Processing pain was not a priority.

Ned came in repeating, “I’m happy. Just happy,” with a painful smile on his face.  Talking about his trauma was too threatening, and broaching the subject led him to bang his head on the wall and wail until it stopped.  It took him years to be able to recall witnessing his parents fighting and his mother leaving never to return.  His adoptive mother had her own abusive past.  She had cut her own parents out of her life, endured a painful divorce, but had gone on to raise fairly healthy children.  However, for this mother, Ned’s daily verbal assaults and devious behavior became personal.  She often “lost it” with Ned and blamed his behavior for making her life miserable.  He was trying to keep caring adults at a distance for fear of more rejection, and for this mother, it worked.

 
Traumatized children find these buttons pretty quickly and begin pushing them to get a response.  The thing is, they did not put the buttons there, our parents did.  We often walk around unaware of why we have instinctive responses to perceived negative stimuli.  This kind of personality style does not just affect our parenting but other relationships; with spouses, friends, and bosses.  So, it’s worth the kind of introspection that Daniel Siegel, M.D. invites in his book, Parenting From the Inside Out.  The work of introspection which requires bringing to consciousness unconscious feelings and motivations is part of the process of becoming a more powerful parent.

Monday, February 10, 2014

Attachment Explained

John Bowlby published his theories on attachment in the 1950’s.  They took some time to catch on, especially in the child welfare arena.  Attachment, Bowlby said, is the relationship that develops between child and parent.  More basic than love, it is essential to survival.  Attachment sets the stage for functioning in the world.  Another word used for attachment is bonding; attachment is the noun, bonding is the verb.  Attachment is a one-to-one and directional relationship, from child to parent.  Parents do not depend on their children for survival, and to the extent that a parent depends on a child to meet his or her needs, it is dysfunctional and damaging. We are not attached to our family.  We are attached to each member of our family in individual and unique ways.  There need be no competition for attachment because there are few limits to the number of relationships we can establish, each of different quality, some closer, some distant, some comforting, some contentious.  Each adult drives this connection primarily through the commitment and care provided the child.  Attachment is a neuro-bio-psycho-social interaction that forms the template for all future relationships.  So attachment is driven by and subsequently drives brain, biological, psychological, and social functioning.  It is a brain-based connection in that, when we are building attachment, we are forming new brain pathways.  The “prime time” for attachment is conception to the first three to four years of life.  This, Bruce Perry, M.D. teaches, is when 67% of brain formation is happening.  The human infant and brain are quite underdeveloped.  The brain has billions of neurons ready to connect through interaction.  This explains why young children learn so quickly.  Then the available unused brain cells begin to fall away.  The human brain is 90% of adult size by age six.  There are still billions of available brain cells, but school and adult learning requires repetition and immersion, much like learning a foreign language.  Perry says abused and neglected children can be thought of as having been raised in an environment of relational poverty without the experiences that build brain cells.  This is probably the most startling point for parents of traumatized children both because the original abuse may have happened during this attachment period and because that window of opportunity seems to have closed.  Yet we know the brain is a malleable organ capable of growth until death.  So, we hold out hope that we can change the brain through nurturing interaction and heal the child through relationship.

            Daniel Siegel calls this “The Dance of Attunement”.  The parent leads this dance by responding to the child’s basic needs which contributes to brain development leading to basic trust, self esteem, and character.  The child is empowered to make his or her needs known developing a sense of agency in the infant and a sense of effectiveness and satisfaction in the parent.  The child perceives herself to be important because the adult demonstrates it.  The infant experiences himself subjectively as good or bad depending on the adult responses.  This intersubjectivity means the parent holds a representation of the child in his or her mind and the infant holds an image of the parent in his or her mind.  Further, this attunement is not just about feeling, it is about action, what parents do, not what they say.  Attachment is developed through experience in all five senses, the most important of which is touch.  In World War II Germany, doctors set up hospitals to care for orphan children.  Despite professional care the infant lost weight and died for lack of touch.  To touch, we would add gaze, smell, taste, and tone.  I note tone of voice because infants do not understand language early on and re-parenting traumatized children requires a focus on tone and not on words for communicating.

            In the simplest terms, attachment is formed through the arousal/relaxation cycle.  As an organism and species we have basic needs in order to stay alive.  Infants need, at basic, nourishment, elimination, interaction, soothing, and sleep.  The need causes a physiological discomfort or arousal in the infant that is usually expressed in crying.  While attachment is directional and driven by the primary caregiver, it is also a reciprocal relationship.  The infant’s role is to make his or her needs known to the extent possible.  When the caregiver reads the child effectively and meets the need for food, clean diaper, attention, and soothing, the infant’s biological and psychological responses are relaxation until the next need appears.  Of course, in early infancy through toddlerhood, the needs are nearly constant.  If the primary caregiver is able to meet the needs in a “good enough” way, healthy or secure attachment forms.  As important as consistent care is the way in which it is delivered.  Infants take us in through all five senses.  Our body language, demeanor, intent and tone are as important to attachment as food and diapers.  The attachment figure brings comfort in its presence and distress in its absence.  The essential ingredients, then, are basic needs, physical and emotional distress, an expression of discomfort, an appropriate reading of the arousal, and an adequate response that meets the needs resulting in relaxation. 

            This means that “distress” is necessary to secure attachment.  The body, if it is healthy, has the ability to signal need through discomfort.  It is not always the most pleasant experience, especially for stressed out parents, but we need the baby to cry.  This begins in utero as the fetus is forming and the womb and the umbilical cord deliver basic needs in the environment of the mother’s body.  We will talk about pre-birth attachment insults later.  But in healthy pregnancy birth it self is the first major stress of the child’s life.  It is a literal separation from the mother’s body and constant care.  According to Daniel Siegel, the infant experiences birth as a life threatening event.  From this point on the new infant begins to develop coping strategies around separation from mother.  Years ago, and sometimes still in the case of caesarian births, the infant is removed from the mother at birth to be cleaned and weighed and cared for by others.  Nowadays, as you can see in the video from the First Five Years collection, we quickly respond to this distress and repair this break by bringing the newborn directly into the waiting arms of the mother.  We will come back to this theme of break and repair as we talk about parenting.

            If repeated successful completion of the arousal/relaxation cycle leads to secure attachment, then frequent interruptions in the arousal/relaxation cycle lead to compromised attachment.  Instead of breastfeeding or formula, hunger is met with unsatisfying water, Kool Aid, or nothing.  Diapers go unchanged and painful rashes develop.  Medical conditions go unchecked.  The need for attention is met with anger or ignored.  The child who seeks soothing is on his own if not physically assaulted.  Even if the care is adequate, it is delivered with little commitment or enthusiasm if not down right contempt and resentment.  In any case, the child is left in a constant state of chronic stress.  This is the kind of psychological and physiological stress that does not go away. 
The causes and reasons for abuse and neglect are many; lack of education, mental illness, poverty, substance abuse, and family discord.  Often parents manage to meet the needs of their children despite struggling with mental illness, substance abuse, and family violence, and do so with determination and support.  However, many children come to the attention of child welfare services investigating abuse and neglect.  Some half million children are subject to the interventions of the U.S. child welfare system.  Parents are offered services to overcome their problems while their children are in foster care.  While the parent-child relationship is of concern, it is not generally the target of intervention even though it is the most important measure of child safety, well being, and permanency.
          Children often enter the child welfare system during the first three years of life interfering with
the development of attachment.  If they enter the system after the age of three the attachment
pattern has generally already been established.  Certainly, many children have developed secure
attachments before their parents are overwhelmed by drugs and conflict.  Then, the intervention
of the system itself in the form of multiple caregivers and multiple placements in foster care can
cause compromised attachment.  This is in contrast to multiple caregivers among various
cultures. 

     In many families, mothers, grandmothers, older siblings, aunts and uncles, and friends of the
family all share in the care of children.  The difference between this family style and foster care is
that the caregivers do not change.  Despite wide cultural differences in parenting styles, what
most cultures have in common is that the life of a child is marked by consistent care and routine.

Monday, February 3, 2014

Kids are Not Dry Cleaning

     With children, the parent-child relationship is primary.  The therapist is not the parent.  There is no special therapeutic relationship that can or should replace the parent-child relationship.  Parents are responsible and need support when they seek help for their child including the ability to communicate with their child about the issue.  If a child cannot talk with his parent about serious issues, that is the problem.  Parenting is 24 hours a day, 7 days a week, 365 days a year.  Therapy usually takes about 45 minutes once a week and is intended to be a short term intervention.  Leaving parents in the waiting room disempowers them.  It says the diagnosis or behavior is the target, not the relationship.

     Kids are not dry cleaning.  You cannot drop them off, have them fixed up, return home and expect it to last without some work with the parent.  A big part of therapy is normalizing issues and reactions to counter the shame that some client's feel about mental health services.  Treating a child individually without parents exacerbates shame.  It also puts the onus on the child to change.  It says, "You are the problem." Working with parents and children together provides more bang for the buck; working on the issues, the communication about the issues, and the relationship at the same time. In fact, parents are the co-therapist for their children.  Healing happens at home, not just in the therapist's office. 

     Some note issues of confidentiality.  Children do not have confidentiality separate from their parents.  Parents have a right to know what is happening to their child.  No medical doctor can keep a parent in the dark about procedures conducted on their child, but child therapists play the confidentiality card all the time.  A therapist will say, "I can talk about our progress but not about what the child said in session."  Who are we protecting?  The California Health and Safety Code and Family Code provide that children twelve or more have the right to consent to their own treatment, especially for sexual and substance abuse treatment, if informing their parents would be unsafe.  The law also gives children the right to authorize or stop disclosure of their health information if informing parents would be dangerous.  But in both cases, the therapist is expected to make repeated attempts to assess the reasons for excluding parents from receiving information and to make efforts to include parents in the treatment of their children.  Otherwise, parents have a right to participate and receive a record of treatment. 

     Some therapists make a special case for adolescents.  But despite growing independence, teenagers need more engagement and guidance from their parents, especially when difficult issues arise.  Therapists spend a lot of time teaching teenagers how to talk to their parents.   The parents need help listening and talking with their teenagers.  How do you do couples counseling when only half the couple is in the room?  In the case of the parent-child relationship, the parent has an even bigger responsibility to the relationship.  The exception is when their is no safe parental figure and the therapist substitutes for that safe base.  This is often the case when a child is removed from parents due to abuse and neglect, or placed in foster care or group homes and parents are absent.  When there is a substitute parent, a grandparent, adult sibling, or foster parent, there is good reason to include the "parenting parent" in the session.  The law allows some substitute caregivers to give consent for treatment.   The court or non-custodial parent gives consent for treatment in child welfare cases, not child welfare workers or foster parents.  However, the law allows therapists to discuss the care of the child with the foster parent or group home staff without violating confidentiality.  It does not help the child to leave these "everyday parents" in the dark.

     A child therapist will say, "I create a safe environment for the child."  That assumes the home is not a safe environment.  What is the goal then?  For lasting results, should our goal not be to help create a safer environment in the home?  The issues that face children; anxiety, depression, learning disabilities, and trauma, can be complex and require multiple interventions including parenting, education, medication, and therapy.  This requires coordinating care not isolating the caregiver who should be the primary director of this treatment.  Parents say, "I don't know what they do in therapy.  They play games."  How is this possible?  Why are we not teaching parents to play with their children if we believe play therapy or other methods are so effective? 

     There are certainly times when, reportable abuse not withstanding, the home environment is so toxic and the parent so unable to participate in treatment, that working with a child alone is the only option for a therapist.  In those cases, we provide the child a safe outlet for their thoughts and feelings and strengthen the child's coping skills.  But this should be the exception and not the rule.  Perhaps some parents just want their kids fixed and do not want to participate in therapy because they fear they will be challenged or asked to change their parenting.  It is easy for a therapist to allow a parent to opt out to avoid losing clients.  Yes, it is sometimes easier to work with children than to work with their parents or parent and children together.  But it does not make it right, ethical, or ultimately effective.

Friday, January 17, 2014

Attachment Explained


John Bowlby published his theories on attachment in the 1950’s.  They took some time to catch on, especially in the child welfare arena.  Attachment, Bowlby said, is the relationship that develops between child and parent.  More basic than love, it is essential to survival.  Attachment sets the stage for functioning in the world.  Another word used for attachment is bonding; attachment is the noun, bonding is the verb.  Attachment is a one-to-one and directional relationship, from child to parent.  We are not attached to our family.  We are attached to each member of our family in individual and unique ways.  There need be no competition for attachment because there are few limits to the number of relationships we can establish, each of different quality, some closer, some distant, some comforting, some contentious.  Each adult drives this connection primarily through the commitment and care provided the child.  Attachment is a neuro-bio-psycho-social interaction that forms the template for all future relationships.  So attachment is driven by and subsequently drives brain, biological, psychological, and social functioning.  It is a brain-based connection in that, when we are building attachment, we are forming new brain pathways.  The “prime time” for attachment is conception to the first three to four years of life.  This is probably the most startling point for parents of traumatized children both because the original abuse may have happened during this attachment period and because that window of opportunity seems to have closed.  Yet we know the brain is a malleable organ capable of growth until death.  So, we hold out hope that we can change the brain through interaction and heal the child through relationship.
            In the simplest terms, attachment is formed through the arousal/relaxation cycle.  As an organism and species we have basic needs in order to stay alive.  Infants need, at basic, nourishment, elimination, interaction, soothing, and sleep.  The need causes a physiological discomfort or arousal in the infant that is usually expressed in crying.  While attachment is directional and driven by the primary caregiver, it is also a reciprocal relationship.  The infant’s role is to make his or her needs known to the extent possible.  When the caregiver reads the child effectively and meets the need for food, clean diaper, attention, and soothing, the infant’s biological and psychological responses are relaxation until the next need appears.  Of course, in early infancy through toddlerhood, the needs are nearly constant.  If the primary caregiver is able to meet the needs in a “good enough” way, healthy or secure attachment forms.  As important as consistent care is the way in which it is delivered.  Infants take us in through all five senses.  Our body language, demeanor, intent and tone are as important to attachment as food and diapers.  The attachment figure brings comfort in its presence and distress in its absence.  The essential ingredients, then, are basic needs, physical and emotional distress, an expression of discomfort, an appropriate reading of the arousal, and an adequate response that meets the needs resulting in relaxation. 
            This means that “distress” is necessary to secure attachment.  The body, if it is healthy, has the ability to signal need through discomfort.  It is not always the most pleasant experience, especially for stressed out parents, but we need the baby to cry.  This begins in utero as the fetus is forming and the womb and the umbilical cord deliver basic needs in the environment of the mother’s body.  We will talk about pre-birth attachment insults later.  But in healthy pregnancy birth it self is the first major stress of the child’s life.  It is a literal separation from the mother’s body and constant care.  According to Daniel Siegel, the infant experiences birth as a life threatening event.  From this point on the new infant begins to develop coping strategies around separation from mother.  Years ago, and sometimes still in the case of caesarian births, the infant is removed from the mother at birth to be cleaned and weighed and cared for by others.  Nowadays, as you can see in the video from the First Five Years collection, we quickly respond to this distress and repair this break by bringing the newborn directly into the waiting arms of the mother.  We will come back to this theme of break and repair as we talk about parenting.
            If repeated successful completion of the arousal/relaxation cycle leads to secure attachment, then frequent interruptions in the arousal/relaxation cycle lead to compromised attachment.  Instead of breastfeeding or formula, hunger is met with unsatisfying water, Kool Aid, or nothing.  Diapers go unchanged and painful rashes develop.  Medical conditions go unchecked.  The need for attention is met with anger or ignored.  The child who seeks soothing is on his own if not physically assaulted.  Even if the care is adequate, it is delivered with little commitment or enthusiasm if not down right contempt and resentment.  In any case, the child is left in a constant state of chronic stress.  This is the kind of psychological and physiological stress that does not go away.  The causes and reasons are many; lack of education, mental illness, poverty, substance abuse, and family discord.  Often parents manage to meet the needs of their children despite struggling with mental illness, substance abuse, and family violence, and do so with determination and support.  However, many children come to the attention of child welfare services investigating abuse and neglect.  Some half million children are subject to the interventions of the U.S. child welfare system.  Parents are offered services to overcome their problems while their children are in foster care.  While the parent-child relationship is of concern, it is not generally the target of intervention even though it is the most important measure of child safety, well-being, and permanency.

   Children often enter the child welfare system during the first three years of life interfering with the development of attachment.  If they enter the system after the age of three the attachment pattern has generally already been established.  Certainly, many children have developed secure attachments before their parents are overwhelmed by drugs and conflict.  Then, the intervention of the system itself in the form of multiple caregivers and multiple placements in foster care can cause compromised attachment.  This is in contrast to multiple caregivers among various cultures.  In many families, mothers, grandmothers, older siblings, aunts and uncles, and friends of the family all share in the care of children.  The difference between this family style and foster care is that the caregivers do not change.  Despite wide cultural differences in parenting styles, what most cultures have in common is that the life of a child is marked by consistent care and routine.

 



                                                                            

Monday, January 13, 2014

Attachment Trauma


Donald and Harold are examples of children who have been exposed to attachment trauma.  Starting before they were born while their fetal brains were developing, their mother was unable to make a commitment to them and her pregnancy that would result in good pre-natal care and a safe environment.  She is on the run, and they are at risk. Thus they are born prematurely already having experienced a series of insults that could have jeopardized their lives, read "threat of death".  Then they suffer the loss of their mother and her daily consistent care.  Remember, because infants do not have "object constancy", that is the ability to hold the concept of a person or object in their memories when the person is not physically present, they suffer the loss of a primary caregiver as similar to a death.  Certainly, another caregiver like a grandparent can mitigate the disruption in attachment, but it requires constant consistent care.  For Donald and Harold this was obviously interrupted if child welfare services was concerned enough about their safety to make repeat visits to investigate. 

     Then starts the second level of attachment trauma, the introduction of multiple caregivers starting with foster parents and then their adult sister.  With their sister they are exposed to traumas of commission as well as omission.  To be certain, with their grandmother, foster parent, and sister there were likely many occasions when they felt safe and loved, but it never lasted.  Their sister's substance abuse leads to unmet needs; gnawing hunger, untreated illness, lack of developmental play, as she cycles between intense interaction and depressive withdrawal.  A note: hunger at this age can cause serious help problems and even death, and feels like it.  The boys experience adults as highly unpredictable.  The relationship violence in the home leads to intense anxiety and fear, trouble sleeping, and anger in twins barely two years old.  No wonder they started developing some really interesting survival skills; watchful hyper-vigilance, sneaky food hoarding, and the ability to either tune out or run from danger.  These are the still small children who stroll into the first, second, and third foster/adoptive homes.  Despite their best intentions and training none of these subsequent parents can offer consistency from one home to the other.  This is the third level of attachment trauma, no one sticks around long enough to trust. These children are in survival mode.

     At this point the boys move into the next home as if they are traveling salesmen.  Full refrigerator, check. Television with cable, check. A place to park my carry on bag, fine.  Someone at the front desk to keep things running, ok. Chores?  "Wait a minute, I don't clean my own room!" Responsibilities? "This isn't my house!" Say thank you? "You're getting paid for this!"   Here's where all of those nifty survival skills become symptoms of some serious mental health disorders.  The new parent repeats herself with her voice rising in pitch each time.  The new teacher complains that the boys do not follow directions or complete their homework.  It's sounding a lot like Attention Deficit Hyperactivity Disorder.  One boy refuses to turn off the television, and the other refuses to go to bed.  When the new parent removes privileges or says no, one boy flies into a rage and the other ignores it.  It's sounding a lot like Oppositional Defiant Disorder.  When stuff starts disappearing or getting broken and the teacher sends one boy to the principal's office, we're heading toward Conduct Disorder.  Throw in two hour tantrums alternating with sullen crying bouts, and Bi-Polar Disorder looks like a real possibility.  "These boys need medication."  "Not taking it." "You need therapy!" "I won't talk." "These children have to move!"  "Fine, I'm checking out anyway."

     Here's where the situation could go either way.  We could begin focusing on the boys' behavior, putting them in a room alone with a therapist, exploring their "feelings" and offering them rewards and punishments for going with the program.  The new therapist would report some success each session.  But the parent would report no change at home.  Or, we could begin understanding the behaviors as symptoms of a much more complicated diagnosis.  You see, if you put these two boys in a house with no parent, they would probably do just fine.  Ok, like any nine year olds, they would eat cookies for breakfast and forget to flush the toilet.  But they probably wouldn't have these huge blow-ups, even with each other.  The problem is... the parent.  The nice parent is scary.  The predictable parent causes anxiety.  From the earliest age the most primitive parts of their brains are primed to fear parents, to fight care, to flee love, even while their minds tell them they need and want it.  It's post traumatic stress disorder, and the relationship is the trigger.  Like the negative poll of a magnet they are repulsed by attempts to get close to them.  And if, by chance, there is a positive pull, they are unable to break free to function independently.  This is relational PTSD.  The abuse these children experienced happened in the context of what was supposed to be a nurturing relationship.  Now they are in a pretty safe situation, but their brains and bodies don't believe or feel it.  Like soldiers back from the war they are hypervigilant with and distrustful of the person they need the most...the parent.
    

Monday, January 6, 2014

Creating Attachment


Donald and Harold*are twins born into a poor family near the U.S. border with Mexico.  Their mother, having given birth to three older children, became pregnant with them during a period in which she was separating from an abusive husband and starting a lifelong addiction to methamphetamine.  Born prematurely at five and a half and three pounds respectively, Donald and Harold were handed over to their maternal grandmother who attempted to keep the children together.  Child welfare services came in and out of the boys’ lives until they were removed at age two.  They were placed in foster care and then back with an older sister and her husband who were starting their own young family.  Like their mother, their sister found methamphetamine to treat what was likely intergenerational depression.  Donald and Harold fended for themselves and attempted to hide from fighting and physical abuse.  Case workers moved the boys from family to foster homes where they grew up, now difficult to place because of age, gender, and number, into a second then third adoptive home with a woman who brought her new eight year old sons to my office.  We worked together three years.