Trauma-informed treatment for damaged adopted children: A comprehensive approach.

Ricky Greenwald, Psy.D.

Poster session presented at the EMDR International Association annual meeting, Austin, TX, June 2001.

Treating older-adopted children entails consideration of multiple issues, including the parents' adoption-related loss history, the child's trauma, loss and attachment history, and the adoptive family's dynamics. Therapist interventions target trauma/loss resolution, parental understanding of a trauma/attachment perspective, and parenting behaviors to facilitate the child's attachment and sense of security.

The treatment of older-adopted children can be complex and requires consideration of multiple issues relating to the child, the parents, and the therapist. Older-adopted children have often been exposed to a range of developmental insults, potentially leading to attachment problems, post-traumatic stress, behavior problems, learning disability, etc. Adoptive parents represent an ethnic and class diverse group that also includes gay/lesbian parents, single parents, and other family constellations. These parents have unique histories and resources that may support or impair their ability to be effective as parents and therapeutic allies.

Working with older-child-adoptive families may be a unique experience for the therapist in certain respects. For example, older-adopted children may be either extremely effective or ineffective at recruiting attachment, so the therapist may feel unusually connected to, or detached from, the child. Also, many adoptive parents are particularly resourceful and effective as treatment allies, and deserve something closer to co-therapist or colleague status relative to parents of other child clients. Thus, treatment with this population requires multiple competencies on the part of the therapist, including cultural competency to work with diverse types of families, as well as a special awareness of therapeutic relationship issues.

This paper represents an informal and preliminary attempt to outline the range of treatment issues entailed in working with older-adopted children and their families. A trauma and attachment orientation guides the overall approach to treatment, and specific interventions are suggested. Specific methods of using EMDR to treat traumatized children are described in detail in Greenwald (1999); the focus here is on how to conceptualize and organize this treatment for older-adopted children.

It takes a lot for a judge to terminate parental rights. By the time a non-infant child is adopted, the chances are very good that s/he has been exposed to multiple and repeated insults, potentially including exposure to toxins, neglect, abuse, exposure to violence, and disrupted attachment relationships. Regarding disrupted attachment, it is important to consider the possible impact of separation from biological parents (even cruel or neglectful ones), siblings, extended family members, foster parents, prior therapists, and other significant people in the child's life.

It is important to consider the full range of issues the child may be facing, including medical problems, attention problems, learning disability, etc., as these may significantly impact functioning. The therapist should be prepared to make appropriate referrals and to work with physicians, educators, and others as necessary.

The child may also be suffering from reactive attachment disorder (RAD) and/or post-traumatic stress disorder (PTSD), perhaps at a clinically significant sub-threshold level. It is important to do a careful evaluation with an eye to these issues. If RAD or PTSD are driving the problem behaviors - the usual reason for referral - these should be systematically addressed. Many treatment failures with older-adopted children are due to failure to appreciate the underlying problem, and only applying behavior modification and/or supportive/expressive therapy, which may be useful but insufficient in such cases.

There are many roads to becoming an adoptive parent of an older child. Most of these roads involve loss, and most of these losses are (at least potentially) of the non-discussable variety, perhaps because they are invisible (the loss of a hope or expectation rather than the loss of a live family member) and/or socially tabu in some way. Examples of invisible and/or socially tabu losses include infertility, being single, or being gay/lesbian (including possible loss of family/community acceptance). The problem with non-discussable losses is that without acknowledgment and social support, it may be more difficult for the parent(s) to work through the loss to resolution. When a new child enters the picture in the wake of an unresolved loss, some of the burden of the loss may be transferred to the child.

The "red flag" for this unprocessed loss being imposed on the child is that the fact of the child's adoptive status is either under-emphasized or over-emphasized. Underemphasis typically takes the form of covert denial, of going to great lengths to pretend that the child is not adopted at all, or is somehow exactly like s/he would be had s/he been born to the adoptive parents. Over-emphasis may take the form of frequently referring to the child's adoptive status, or of treating the child differently in some unnecessary way. For example, the child may be indulged or scapegoated. Parents who are not impaired by unprocessed loss are able to openly acknowledge the different-ness of the child's adoptive status, and of their family constellation, and are able to convey a positive view of this different kind of family.

An additional loss may occur following the adoption, if the parents experience disappointment, frustration, anger, or rejection following repeated interactions with the child. This may occur as a result of the child's severe behavior problems; parents commonly become frustrated with chronic misbehavior, and then may become angry at the child and feel like giving up. There are two main contributors to this pattern. One is that the child has a serious behavior problem due to emotional problems, prior reinforcement experiences, attention deficit hyperactivity disorder, or other typical reasons.

The other factor is specific to this situation, and may ensue only following a "honeymoon" period of some weeks or months. The theory here is that the child finds it intolerable that his own (biological) parents might be flawed, so the child has justified his prior mistreatment and rejection by taking the blame onto himself. When he is in a new family and finds that he is not being mistreated, he is forced to face the possibility that maybe his (original) parents really are bad. This is intolerable. So he generates such terrible behavior that he forces the new parents to mistreat and/or reject him, thus confirming his belief in his own badness and his original parents' goodness. We often call this "loyalty" to the original parents, but it may in fact represent the child's effort to retain a sense of feeling protected and attached.

A related issue is the child's fear of being retraumatized (mistreated, rejected) in the new home. So he generates bad behavior to force the mistreatment or rejection, to keep it under his control. This can also be viewed as a test of the new parents, something they must withstand and resist before he is really able to trust them. However, such bad behavior is often very challenging to adoptive parents and they may be tempted to fail the test by becoming angry and retaliating in various ways. Adoptive parents are people too, and they may be sensitive to what they perceive as rejection by children who do not appreciate them and who appear to deflect their caring.

Children with RAD are particularly challenging for adoptive parents, who may invest months or years of love and effort into the child and "get nothing back" in terms of affection or emotional gains. They feel, often accurately, that the child does not care about them except to use them for material gain.

Adoptive parents may also be uniquely resourceful. Those who have children by choice (whether by adoption or the other way) tend to be older, more mature, and more financially stable. The (typically) long process of adopting a child, while perhaps an ordeal, also provides a preparation period for the parents, during which emotional investment may be fostered. Many adoptive parents have relatively good mental health as well as social support networks. Parents who adopt damaged children have the advantage of being innocent, of having done the child no harm, so although they may have to earn the child's trust, at least they are not personally contaminated by past bad actions. Many parents adopting older children understand that the children will require an intensive therapeutic environment, and are prepared to provide that. Adoptive parents are often very dedicated to their children and are both committed to and capable of working closely with the therapist to help their children to heal and to achieve a more normal and healthy developmental path.

Working with older adopted children and their families can be both challenging and rewarding. Multiple expertises may be required in addition to the standard child and family treatment repertoire. It is important to be culturally competent in a wide variety of family constellations and subcultures, to be able to understand the nature of possible losses the parents may be carrying, and to assist the families in defining themselves in an appropriate and positive manner. It is important to understand the specific issues related to older-child adoption, including the child's loyalty to her original parents as well as her fear of further mistreatment and/or rejection, and the parents' possible unresolved loss as well as their sensitivity to perceived rejection by the child. Both child and parent may have a special concern with being unwanted, being second choice. The treatment focus is likely to include disrupted attachment (and enhancing attachment in the adoptive family), PTSD, and problem behaviors, requiring further areas of competency.

The therapeutic relationship may require special attention when working with older-child adoptive families, because the therapist may have unique types of involvement in the family for a variety of reasons. An RAD child may be particularly difficult for the therapist to relate to or invest in. On the other hand, many adopted children are uniquely able to recruit attachment figures, including therapists, who may find themselves rather invested in these children. Parents may appropriately play more of a co-therapist or collegial role than in many therapy contexts, so the therapist has to figure out how to treat them with the respect that they deserve as co-therapists as well as the somewhat different respect and consideration they deserve as therapy clients. Some of the therapist's interventions may involve actively facilitating parent-child bonding during the therapy session, thus inevitably making the therapist a participant in the bonding process. Finally, adoptive families may have an appropriate but expansive definition of family that incorporates extended family, close friends, and other significant people such as therapists.

For all these reasons, therapists who work with older-child adoptive families may find themselves more involved with these families, more feeling like a family member, than in other therapy contexts. This does not mean that the therapeutic frame should be abandoned or that boundaries are not important. Rather, it requires that exquisite attention be paid to these issues precisely because the lines may be in a different place, and the customary methods of drawing these lines might not be available.

The earliest phase of treatment normally includes an evaluation component, some of which should be done with the family together, or at minimum with one parent and the child. The evaluation process, at its best, includes ongoing feedback, both to provide information to the family and to learn from their responses. By the time the evaluation is completed and the formal feedback is provided, the informal feedback provided along the way - and the family's responses - should have created a shared conceptualization of the issues so that acceptance of the therapist's formal feedback is a foregone conclusion.

The therapist can use a genogram to map the family constellation and history, including adoption, birth parents, etc. This gives the opportunity for the therapist to introduce the idea that it is okay to talk about the adoption and related matters, and opens the family history as a possible focus of treatment. For example, the therapist may choose to sensitively introduce possible family challenges, perhaps by saying, "Sometimes children who have been through several foster placements before being adopted believe that no one will keep them. Then they act bad to see if their adoptive parents will get rid of them or not. Did that happen in this family?" (In meeting alone with the parents, the therapist can provide similar opportunities to discuss difficult issues, for example regarding the parents' feeling rejected by the child, or feeling frustrated and discouraged.)

Since adopted children are typically concerned that their own defects caused their rejection by their birth parents, it's important to work towards correcting that perception from the onset of treatment. During the genogram construction the therapist may inquire about why the child was removed from the birth parents, and then say something to convey that the child may have been cherished, but by parents who were not capable of providing ongoing care, for example, "It sounds like your [birth] mother had a lot of her own problems, and couldn't take good care of you every day. So she helped you find this family because she wanted to make sure you were being taken care of." The therapist can also use this opportunity to float some positive ways of defining the family, for example, "So your [adoptive] parents didn't want just any kid, they looked and looked and you were the one they chose." Of course, such interventions should be accurate, based on the material provided by the family.

Following the formal evaluation phase, the therapist normally offers her view of the presenting problem and her suggestions for what to do about it. Although this may be done with the child present, it is often better to offer more comprehensive feedback to the parents first, and then together to present a shortened version, with a more selective focus, to the child. Since in many cases the treatment will entail a significant focus on attachment enhancement and on trauma resolution, it is essential that the case formulation includes explanations that lead to this type of treatment focus. In general families will find case formulations understandable and credible when they are presented in plain language and when they are "experience-near" rather than abstract and theoretical. In other words, the case formulation should be a story in which the child learned reasonable things from unfortunate experiences. The therapist's job here is to tell the child's story in a way that explains how trauma and disrupted attachment may have contributed to the child's presenting problems. For example, a child's RAD might be explained as follows:

"You told me that no one was really watching your [adopted] son for the first three years of his life. He was just left with a pack of kids and there was no adult to see if he was cold or hungry. Over time he probably learned that he couldn't count on anyone else to take care of him, that he could only count on himself. But that's how children learn to care about other people, by being cared about. Instead, he learned to say, "No one cares about me, why should I care about them?" That's a very angry thing to say, isn't it? But that's what he learned, and now you see how he doesn't really develop attachments to people, he's only nice when he wants something from you. He's only in it for what he can get."

This is a story that any parent can understand. It explains how a child learned a reasonable, if unfortunate, lesson from his experiences. Similarly, a child's PTSD might be explained as follows:

"When children are beat up so many times, for no real reason, the way your daughter was, they learn to be afraid that it can happen any time. They learn to watch out for it, they're always on the alert. It's so scary to believe that bad things like that can really happen for no reason at all that they try to make up reasons, so they can get control over when it happens. Like, "It won't happen if I don't wear red," or, "It won't happen if I stay really quiet."

This type of case formulation helps to teach that the child's past experiences and related needs are driving the current problems or symptoms. This perspective helps parents to feel less rejected or inadequate because they come to appreciate that they did not cause the problem and that it's not about them. When the parents no longer take the child's problem behavior as a personal affront or failure, the parents are less likely to want to retaliate by rejecting the child, and more likely to be able to focus on the child's needs in a productive way. This case formulation also provides a context for the parents to take on an active role in healing their child, helping him to feel more safe, secure, and attached.

Once the evaluation and feedback portion of the treatment has been completed, the therapist can recommend a specific course of action, including specific treatment activities with supporting rationales, and possibly other activities as well. For example, the child may be referred to a psychiatrist for a medication consultation, or to an educational evaluator for a possible learning disorder. The interventions that follow are often included in the recommended treatment plan. Once the therapist and the family agree on a course of action, the therapist has a mandate to proceed with the interventions discussed below.

It is important to remember that many parents have an assumption that psychotherapy is long-term and features the therapist providing a corrective relationship for the child. This "traditional" model of child psychotherapy is not the preferred approach in this situation. Rather, the therapist's goal will be to help the parents provide the corrective relationship. The therapist may also provide elements of corrective relationship, at least to the extent needed to facilitate trauma resolution. However, the emphasis should be on the parents' role in healing the child's trauma and in helping the child to develop a strong and secure attachment to the parents. This emphasis is more empowering to the family and more valuable to the child, who will be able to maintain his attachment to his adoptive parents long after the therapy is over.

An essential element of trauma-informed child therapy is to enhance the environment's effectiveness in conveying protection, predictability, safety, and security to the child. The first step is to eliminate physical threats to safety; this has typically been effected by placing the child in the adoptive family. However, traumatized children often continue to feel unsafe even in objectively safe situations. This is because a relatively innocuous event may trigger a reminder of the more significant and dangerous events from the past, causing a degree of anxiety that does not objectively appear warranted. Thus, many adoptive parents report that their children over-react to minor stressors, get angry over nothing, become fearful for "no reason," etc.

The trauma/attachment-based case formulation can be used as a rationale for many of the standard parent-training discipline methods, including time out, incentives, etc. For example, the therapist can explain that when the parent is not in control, the child feels insecure; and if the parent must repeat requests, argue, yell, or hit, the parent is not in control. Similarly, if the parent makes overly harsh punishments that are later retracted, the therapist can describe that as breaking a promise, that makes the parent seem unreliable. Parents can be taught to discipline very quickly for very minor infractions rather than waiting for repeated infractions or escalation, when the parent is likely to be more frustrated or angry and the punishment is likely to be bigger. Quick, small punishments such as brief time outs help to keep the parent in control while helping the child to receive the reassurance of discipline without the harshness that is often associated with inappropriate discipline.

Even when the therapist provides a rationale that allows the parent to perceive herself as being loving and helpful to the child by providing consistent discipline, and even when the therapist trains the parent in specific discipline methods, parents should not be expected to master these methods immediately. The therapist should predict only limited success at first and portray this as a process of developing skills and habits, not an immediate leap to perfection. The therapist can also explore with the parent perceived obstacles to successful implementation of the recommended approach. This ongoing problem-solving approach to parent training helps the parents to feel supported and successful over time.

The foundation laid during the case formulation will be critical to helping the parents problem-solve their discipline approach. The therapist's job here is to directly relate the themes presented in the case formulation to specific child behaviors and parent strategies that can be implemented on a daily basis. (I half-joke with my trainees that they should use the words "safe" or "safety" at least 10 times per session.) It is also essential that the therapist continue to assist the parents in focusing on the child's needs, and the meaning of the child's behaviors, and to distinguish these from the parents' own reactions to the child's behavior.

For example, after the first parent training session, the parent may return and report that when his child did not come inside until 10 minutes after she was called, he grounded her for the following week; but three days later he relented and let her go out to play again. The therapist will certainly want to help the parent to understand the importance, based on the child's needs, of the parent maintaining sufficient self-control to avoid over-punishing, and of the parent keeping promises (including punishments) once made. To help the parent achieve these behaviors, it may be necessary to help the parent focus on his own escalating reaction to the child's misbehavior, so he can catch himself earlier in his own escalation and provide discipline earlier and in a more appropriate and controlled manner. In some cases the child's problem behavior triggers a reminder of the parent's own trauma history, and this may become the focus of treatment if necessary to facilitate appropriate parenting.

One typical obstacle to effective discipline is that parents may confuse discipline with anger, harshness, and revenge, and be reluctant to inflict this. It can be very helpful for the therapist to help parents to distinguish the positive protective and educative functions of discipline from the negative revenge-like functions that may have occurred in their own experience. Another strategy is to have the parents project their child's development into adolescence, first with a poorly controlled discipline style and then with a positive and effective one. In general, parents are very responsive to parent training when they understand that it offers them a role in healing - not hurting - their child.

Because effective trauma treatment is relatively new, parents may assume that the child must learn to live with a(n actually unnecessarily) high degree of permanent damage. In many families, once the parents have gotten a good handle on the discipline issue and family interactions have taken on a more consistently positive tone, they are tempted to terminate treatment. (This also may occur when the older child has been practicing self-control skills, which may be taking place simultaneously.) This is because things are so much better than they have been. However, they are not nearly as good as they could be. It is important for the therapist to predict this temptation for premature termination and to explain why it would be premature: because the trauma memories have not yet been treated, and significant vulnerability remains. This vulnerability may be demonstrated on a frequent basis, for example the child may continue to have fears or other strong reactions in certain situations. Or it may not become apparent until a new stressor arises, at which point the child may cope poorly.

Trauma treatment entails multiple phases, many of which may have already occurred, including environmental manipulation for physical safety (e.g. adoptive placement); psycho-education (e.g. the trauma-based case formulation); and environmental manipulation for emotional safety (e.g. parent training). With chronically/multiply traumatized children, the next stage of trauma treatment would be to increase affect tolerance by helping the child to develop specific skills to cope with affectively challenging situations, and to feel stronger and more competent in general (for examples of such interventions see Greenwald, 1999). All these steps lead up to the child being able to directly face and work through the trauma memories.

The research on trauma treatment has been done primarily for those with PTSD; however, some related research on trauma treatment for individuals with sub-threshold PTSD symptoms indicate that similar treatment principles apply. As a clinician I generally assume that children who are troubled by trauma memories (and/or related symptoms) can benefit from trauma treatment whether or not they meet criteria for PTSD.

There is extensive evidence to suggest that direct trauma treatment is both more effective and more efficient than indirect trauma treatment. That is, for maximum treatment effect it does appear to be necessary to talk directly about the trauma memory in a focused way, rather than relying solely on therapeutic relationship, symbolic play, or other means to address the trauma. As a clinician I prefer eye movement desensitization and reprocessing (EMDR) for this portion of the treatment, because it is acceptable to most children, it is more rapid than other methods, and its effect appears to be equal to or greater than other methods. Although there is some research to support this opinion, more research is needed. While I will be discussing EMDR, several exposure variants are also an option, either instead of EMDR or in combination.

To support the development of affect tolerance, and to introduce EMDR in a gradual manner, the therapist can first use eye movements to develop resources such as Safe Place, past success/happy experiences, and Getting Stronger. The latter can be done by asking the child what she does to get stronger (e.g. eat well, get enough sleep, walk to school, swim, ride a bike, etc.) and what image she might have of being strong (e.g. being bigger, carrying something heavy). Then the therapist can have the child visualize (during eye movements) doing the various things in an imaginal "movie" ending with the strength image, while repeating (out loud or to herself silently) "I'm getting stronger." The child can also be asked to demonstrate her strength by doing pushups, jumping jacks, or running a certain distance. As time goes on, the therapist can repeatedly refer to this strength-building to help the child with affect tolerance, for example, "Wow, that's a lot of pushups, 5 more than you did last week. Do you think you're strong enough now to think about [that bad thing] for a couple of minutes?" Children like the idea of getting bigger and stronger, and like to show adults how well they can do things, so this approach does seem to help children to face difficult material for at least a brief period.

Even with this approach it is generally best to focus first on relatively minor upsetting memories, such as what happened yesterday in school, before going to the major trauma memories. This gives children a track record of using EMDR on upsetting memories and then feeling better. This track record is not only about EMDR's tendency to lead ultimately to feeling better, but about the child's ability to tolerate a brief period of distress.

When it is time to address the major trauma memories, resources specific to the target trauma should be developed. This can be done in conversation and/or in play, but then the resources should be installed by having the child imagine the resource during eye movements. Typical resources might include weapons, helpers, etc.

Parents may play a role in the EMDR/trauma resolution phase of treatment. With younger children the parent may tell the story, in a fairy tale format including a happy ending, with the child present (see Joan Lovett's work for more detail on this approach). The therapist slows the story at key points to do eye movements with the child. This is repeated until the trauma is resolved.

Additionally, even with the more standard EMDR, some children prefer to have their parent(s) present during the trauma processing. The risk here is that the child may become so concerned with the parent's distress that she focuses on taking care of the parent rather than processing the trauma. The therapist can generally resolve this preventively by instructing the parent to contain his reaction and to sit behind the child so his face can't be readily seen. When parents can successfully support the session's focus on the child, the parent's presence can support the child's ability to continue through difficult parts of EMDR; and this experience can contribute to the parent-child bonding.

In general, the same principles apply to processing loss. However, the goal of trauma processing is typically that the child "gets over" the trauma by integrating the experience and putting it in the past. On the other hand, with loss there is generally an additional goal of finding a new and adaptive way of maintaining the lost relationship, for example by doing something to honor the memory of a dead person. It can be particularly challenging to find a way to maintain a lost relationship when the "lost" biological parents may have a history of irresponsibility and even aggression towards the child.

The adoptive parents can support the child's continuing relationship to his biological parents in a number of ways, depending on what is most appropriate in consideration of the child's needs for safety, stability, and bonding to the new parent(s). The therapist can help the adoptive parents to understand that, paradoxically, they are not in competition with the biological parents, but rather that the more they can demonstrate support for the child's relationship with the biological parents, the less conflict the child may feel regarding bonding with the adoptive parents. In other words, the child should not feel that he must renounce one set of parents for the other, but rather that each set of parents supports the child's relationship with the other.

This does not mean that the child should necessarily continue to encounter his biological parents on a frequent basis or without adequate supervision during contacts. Such unregulated contact could be extremely disruptive to the adoptive family and to the child. Rather, the logistics of how the child can most beneficially maintain his relationship to his biological parents should be carefully considered. In extreme cases contact may be limited to birthday cards, an annual exchange of photographs, or remembering the parents in the child's prayers. Adoptive parents can also support this relationship by encouraging/helping the child to create a "life book" of notable parts of his past, including stories, pictures, documents, etc. Photographs of the biological parents may be shown in the adoptive household, perhaps in the child's room or on a wall with pictures of other family members. There are many creative ways of demonstrating support for the child's continuing relationship with biological parents, that do not rely on specific behavior on the part of the biological parents.

Virtually everything described above will potentially contribute to the child's attachment to his adoptive parents. There are also explicitly attachment-focused interventions (based on the work of Joanne May), the simplest of which will be described here. This does not represent a comprehensive approach for the most severely attachment-disordered children, which is beyond the scope of this paper.

After preparing the parent in advance, in session the parent can tell the story of the child's adoption from the adoptive parent's perspective. This story can include the parent's desire for a child, the parent's search for a child, the parent's interest in this particular child and how that grew, their early meetings, etc. The emphasis should be on the child's being wanted, chosen, and cherished. This type of story is typically told with the parent holding the child in her lap, and with the therapist initiating bilateral stimulation for the child, perhaps eye movements or taps on alternating feet.

Another attachment story is more fantasy-based, and is intended to not only facilitate bonding but help the child to recover some of his possibly missing positive developmental experiences. Here the parent tells the child the story of his early development the way it would have been if he had been with the adoptive parents at that time. For example, the parent may say, "if you had been with me/us when you were a new baby, I would have wrapped you up in a warm blanket and showed you to all my friends. And when you cried I would feed you milk..." This can be done in great detail covering the child's entire wished-for history; it can also be broken up so that it may take more than one session to complete (sometimes 5 or 10 minutes of this is enough for one session). This story is also typically told with the parent holding the child, and during bilateral stimulation.

These attachment stories may be repeated at bedtime and naptime and become part of the family lore. Eventually some parents report that they are able to use the attachment stories to help soothe their children. For example, one mother told me that when her daughter began to exhibit excessive nervous energy and hyperactivity, the mother would scoop her up, hold her, and tell her the story, and the girl would sink into her mother and calm down.

Treating older-adopted children is complex and requires multiple areas of skill, expertise, and awareness. The trauma/attachment perspective can provide a useful and versatile framework for organizing the range of interventions that may be required.