Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, October 24, 2012

"My Adopted Girl": Many Issues, Many Interventions



An organization I belong to recently received an e-mail from a mother with the subject line, “my adopted girl”. The mother, whom I will call M, tells her story and asks if there is a good book to read to help with the troubles the family is having.

M’s daughter is now 8 and ½ and has been with M’s family since she was 17 months old. She was severely neglected by her 15-year-old parents, according to M. Daughter was angry when first brought into M’s family and M describes her situation by saying “it was hard for us to attach” (although she does not explain exactly what she means by this).  The biological mother was not only very young but was said to have had ADD and bipolar disorder and to have used and cooked meth in the home where M’s daughter lived with her.

M says she has always been very firm and consistent with this child, but is now concerned because the daughter steals and lies and does not seem remorseful. M is puzzled about what consequences might curb these behaviors and is worried that as the daughter gets older she will discover even more serious and dangerous behaviors.

There are some other interesting features to the situation. One is that M’s family also adopted three of this daughter’s siblings, one of whom came to them at 9 months after five months of foster care and a brief return to the biological mother. According to M, none of the siblings have any of the same issues that the daughter she is concerned about has.

M also brings up briefly the possibility that she herself has been overwhelmed by the demands of this family, and states that the daughter’s own problems may be only part of the picture. (This is an important insight and makes me feel optimistic about M’s ability to think through and handle whatever is happening.)

Finally, M states that her husband keeps asking if they should get the daughter therapy or not. She doesn’t mention what is meant by this, exactly.

I am going to make some comments and suggestions, but before I do so let me say that I have never met any member of this family and cannot make specific statements about them. In addition, I am not a clinical psychologist and am not presenting myself as such or offering any services.

The first point I’d like to make is that on the basis of M’s description it does not appear that the daughter has Reactive Attachment Disorder, in spite of her troubled early history. Stealing and lying, though very disturbing and problematic behaviors, are not aspects of Reactive Attachment Disorder. I think it would be a mistake to seek therapy that concentrated on attachment issues as a major cause of these behavior problems. If M and her husband seek treatment for this child, it would not be sensible to look for a practitioner who focuses on attachment therapy or on attachment as a primary problem. The fact that the other siblings do not share this daughter’s troubles indicates that this is not simply a problem of separation and adoption.

A second point is that the biological mother’s ADD may have been passed on genetically to this child, and she may be impulsive and lack self-control for that reason. Why do the other siblings not have the same trouble? Genetic transmission does not give the same results every time, and what’s more it isn’t necessarily the case that all these children have the same father. If ADD is a factor in the daughter’s behavior, she may benefit from medication.

Children who have been exposed to drugs either before or after birth have usually been exposed to alcohol too. Effects of fetal alcohol exposure may or may not be apparent in the child’s appearance, but a medical examination might help on this. If alcohol exposure is an issue, the daughter may need special education and may also benefit from medication.

The story of the daughter’s early life also suggests that she may have had little early language experience and may have had language delays with which she has not yet caught up. These would make her easily frustrated, especially in school, and could result in undesirable behavior and poor understanding of other people’s wishes and the consequences of what she does. I would suggest a speech and hearing assessment and speech therapy if recommended.

M’s recognition that she may be overwhelmed is an important one. A mother’s frustration, anxiety, and depression can have devastating effects on children’s development. In this case, it seems that the troubled daughter was adopted first and the other siblings later--  M does not make this completely clear. It is easy to see how even very competent parents could be thrown by dealing with one angry toddler and then having three more young children added to the mix. None of the children may have gotten all the attention they needed at this point, but the troubled daughter may have biological vulnerabilities that gave her real difficulties in giving up the attention she had been getting.  M’s e-mail sounds as if she still feels overwhelmed, and this may be one of the keys to the whole set of issues. A good counselor (well-trained and licensed) for M could help support this mother and enable her to help the troubled daughter as well as the other children (who must be affected by their sister’s behavior). This is not to suggest that I think M is emotionally disturbed --  simply that having some professional support can be very beneficial to someone who has taken on the responsibilities M has.

Finally, I’d like to address M’s question about appropriate “consequences”. I doubt that changing ways of punishing the troubled daughter will be of any use. If punishment is to be used, it can only be effective if it occurs very quickly after the undesirable behavior, and this is hard to do with stealing and lying, where the problem is usually not detected until later. In any case, the first question should be whether any of the points I mentioned before can be of help in correcting these disturbing behaviors. More attention, more guidance, and the use of cues to remind a child about what to do are more likely to be effective than any specific “consequences”. Although this child is a little older than most for whom this treatment works, some of the ideas of Parent-Child Interaction Therapy can be very helpful.

I hope M and her family will be able to find a good outcome for this very challenging situation.

4 comments:

  1. My first thought is that there may be more trouble to come for this family with the younger siblings---including the possibility of ADHD, bipolar disorder, and FASD. But sometimes behaviors that are more obviously abnormal in older kids get seen as age-appropriate for younger kids.

    Second, given the birth mother's history, not only would therapy be an important next step, but so would a good pediatric psychiatric evaluation. ADHD and bipolar disorder often go hand in hand, and getting the right mix of medications can be crucial to successful treatment. Hospitalization is often the quickest way to get the med mix correct. Doing the tweaking as an outpatient can take much longer if appointments are available only once every 2-3 months---not uncommon given the shortage of pediatric psychiatrists. But it doesn't sound like this child's behaviors are anywhere near the violent level that is required for a hospitalization, so that's probably not an option.

    Also, I highly recommend In-Home Therapy, in addition to outpatient therapy (which should probably include at least the mother, as well as the child). A good In-Home Therapist can be invaluable in setting up (and monitoring) a consistent, supportive schedule of routines in the home, and be a wonderful role model for how to deal with conflict.

    One of the sad facts about foster/adoption is that most of the children arrive in new homes with a history full of neglect, abuse, loss, and trauma, as well as prenatal exposure to alcohol (which is far more damaging than prenatal exposure to drugs, though it has gotten much less attention in the popular media) and a genetic history that can make a child more vulnerable to a variety of psychological disorders.

    Think about it: the vast majority of families are able to care for their offspring regardless of how one member or another may fall down on the task of parenting their children. But the children who end up in foster care, waiting to be adopted, tend to come from not only a nuclear family that is dysfunctional/abusive, but from an entire family constellation that has no resources to care for that child. Sometimes, multi-generational patterns of child abuse/neglect is the sole reason; sometimes multi-generational drug/alcohol abuse is the sole reason; sometimes generation; sometimes multi-generational mental illness is the sole reason.

    But in my experience, as a foster/adoptive mom for over a decade, multiple factors tend to be at play, over a wide swath of a family, in order for them to lose a child to the system.

    I would also note that the ramifications of ADHD over the lifespan can be extremely damaging. While many like to talk about the over-diagnosis and over-medication for ADHD in schoolchildren, I've seen the ravages brought about by undiagnosed, self-medicated ADHD in adults who unintentionally become parents, resulting in addictions, criminality, and social isolation.

    While it will be helpful for M to look at her parenting skills, it is unlikely that even a great improvement in her parenting skills and relationship will be enough to treat her child's issues, though there is always room for improvement specific to the particular children in your care.

    I've found that Ross Greene's book "The Explosive Child" is a wonderful introduction to a parenting approach for high-intensity children that does not get caught in the trap of thinking that rewards/consequences are the ways to teach children skills that they are missing. There are numerous videos of Ross Greene on youtube explaining individual parts of his approach: it's an immediate, free way to become familiar with his approach.

    Karyn Purvis, in her book "The Connected Child," also provides good help to parents that does not take a punitive approach and serves as a wonderful reminder to restore gentleness and acceptance to your interactions with your child when you're feeling at the end of your rope. I would pipe her voice into my ear if I could!

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  2. Thanks, Marianne, there's a lot for M to consider in your comments. I do want to point out that by counseling for M I didn't mean specific parenting skills, but support in coping with her natural emotional reactions to the turmoil of her family.

    I want to note, too, that attractive as in-home therapy sounds, it's important to be careful about this. If you are referring to a home visiting program like David Olds' program, yes, that's been shown to be very advantageous. However, few professionals who work in conventional ways with parents and school-age children are willing to make home visits for therapy. Of the people who do make home visits for treatment, many of them are unconventional and even questionable in their approaches.

    I would also recommend some caution about the Purvis book because of her past connections with some dubious people and practices, at least two of which I see referenced in the book.

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  3. Jean, I guess we're lucky in Massachusetts, where a state-coordinated program of mental health initiatives for children has made both mobile crisis support as well as in-home therapy available through reputable mental health agencies state-wide. We have a Master's level clinician working with us, under supervision with the psychologist director of the program, and in communication with all the other players in my daughters' care---including their psychiatrists, outpatient psychotherapists (Psy.D.-level), and my youngest daughters' social workers and lawyer. Yes, confidentiality is an issue! But the care is professional and mainstream, and is enormously helpful---and is fully reimbursed by mainstream medical insurance.

    Again, another wonderful aspect of Massachusetts law is that mental health services must be covered at the same level as other health services by every insurance company that writes insurance policies in the state. It doesn't eliminate all the quacks, who prey on people's insecurities and empty out their wallets, but it does tend to funnel people towards the professional and licensed providers because they're covered by insurance, where the fringe folks aren't. For un-insured children in other states (again, in Massachusetts, the rate of children being insured, by the state if their parents don't have family insurance, is somewhere around 98%), there is, I believe, a greater chance that children may be seen by "unconventional" providers, as you put it, since so many parents have to pay out of pocket for any therapy.

    And, I suppose, that's another aspect of treatment for behavioral/psychological issues in children: it varies so much from state to state, and even within states, depending on the density and quality of services available. I don't know, for sure, that quacks can gain a stronger foothold in rural areas without lots of other options, but that would be my guess.

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  4. Yes, you are lucky! The insurance coverage, the mental health parity, the home services-- those are all so desirable, and so unavailable to most people in the U.S., especially, as you say, outside major cities.

    It's very hard to explain this situation to British readers, who expect there to be uniform laws and services in a single country. But not only does neither of the presidential candidates state concern about this, there would undoubtedly be shrieks of Government Interference if there were any proposal to create a nation-wide system-- same as with school curricula.

    If you can tell me,I'd be curious to know: how does Mass. manage to exclude the fringe element? Is it left to the insurance companies (who will often do it), or to a professional board,or to parent advocates?

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