To bridge the emptiness in search of psychic pain
With grace to reach inside a troubled soul
To heal the mind and heart and bridge the loneliness of discontent
That is my grace and gift
A mental health professional (psychologist, psychiatrist or social worker) can play three important roles along the foster child's road to bonding and permanence. A correct diagnosis is necessary to get started. Then treatment may be necessary to address one of the many psychological disorders to which foster children are particularly vulnerable. Finally, the mental health professional can attest to the presence or absence of bonding by performing a bonding evaluation.
Diagnosis
Because of their history of abuse and neglect, often followed by multiple placements and delay, foster children are particularly vulnerable to disorders that involve relationships and attachment. These diagnoses include Reactive Attachment Disorder, Oppositional Defiant Disorder, Attention Deficit/Hyperactivity Disorder, various Learning Disorders and Adjustment Disorders. More serious are Conduct Disorders, Major Depression and Autism. Obtaining the correct diagnosis through a Childhood Mental Status Exam is the first step. If medications appear appropriate, then a physician or psychiatrist will be needed.
Treatment
Children suffering from Reactive Attachment Disorder make parenting exceptionally difficult. The RAD child may shut down emotionally and seem unreachable, not understanding love nor trusting it. The child may perceive affection as a threat and respond accordingly. For this reason, we will use RAD as an example to show how a therapist can help a troubled child.
At most, a therapist is likely to spend one or two hours per week with the child. Parents spend every day. What parents do or do not do will have considerably more influence on the child’s well-being than what happens in the therapist’s office. Consequently, to reach and heal the RAD child, a wise therapist will work primarily with and through the parents. The main job of the therapist is to structure appropriate means of connecting with others, especially family members. The child’s therapist will help the parents to become the primary healers. More than with any other mental disorder, the healing for Reactive Attachment Disorder takes place in the home.
Don’t miss the obvious. RAD is not amenable to cognitive behavioral therapy, crisis intervention or even to behavior modification. Bonding cannot be forced, but occurs naturally when the stage is set and the time is right. Broken relationships are a major cause of RAD. They lead to hesitance in reconnecting and indifference. The cure involves trust, at least the beginning of trust, and learning to share important events over time in daily life. Meaningful and vital relationships do not occur in artificial environments like offices. They develop in that wonderful mix of emotional entanglements within the family.
Five obvious factors should constitute the basis of any therapy that involves the healing of relationships.
Permanence is critical. Every child has the right to a permanent home. One might even argue that “permanent” is one of the hidden assumptions built into the idea of a “home.” The therapist’s first job is a social work task, working with the welfare department to do everything possible to achieve permanence. Help the child remain with the birth parents if possible. Arrange for in-home services. If the child must be removed, work to shorten the time in limbo. Help evaluate available kin. Promote concurrent planning to minimize multiple moves. Try to approach every placement away from the birth home as if it could be the last one. Find adoptive parents. Foster care is, or should be, temporary. Therapy begins with a permanent home.
Bonding is not a transferrable skill but takes place between specific individuals. To facilitate bonding with a person who is likely to disappear is dangerous. Losing a loved one hurts badly. The loss may cause the child to reconsider the risk of future attachments and vote to “opt out.” Repeated loss entrenches the attachment pathologies.
A sensitive therapist realizes that foster parents face a serious dilemma. On the one hand, foster parents are likely to attach, even to fall in love with the children in their care. On the other hand, if the child trusts and loves them in return and then is removed, trauma results. To anticipate this dilemma, the therapist should do everything possible to prevent or minimize multiple moves, and to shorten the time in temporary care.
Structure connecting. As soon as a permanent home is established, facilitate the avenues of attachment. Attachment and bonding occur naturally and so should the treatment of RAD. The therapist should remind the parents to smile at their child, and touch, and ask questions. Read or make up bedtime stories. Consider getting a pet to love and be loved by. Parents might be advised to notice at least two extra things about their child each day.
Shouting and angry behavior are personal reactions and may actually be a step forward away from the detachment of RAD. Parents of an RAD child should avoid grounding and time-outs as discipline, as these procedures tend to isolate and further alienate the child. Instead, keep the child nearby so he or she can interact.
Peers are critical partners, perhaps even more than parents. The therapist will advise parents to encourage participation in groups such as 4-H, school clubs and sports, summer baseball, soccer, or the swim team. Be there and cheer them on, even if they are not stars. Welcome sleepovers and two-person games on the computer. Parents should be urged to do what they can to provide possibilities for contact with peers, even when that contact involves arguing and disagreements. Bonding has positive and negative aspects, but it cannot happen without the opportunity to interact.
Model emotions and compassion. Reasoning and logic are analytic and general, but emotions are personal. The therapist might encourage parents to let their own feelings show. Children need to learn that their parents have feelings, too. Foster/adopt parents should feel free to laugh with their child. Some things are very funny. It is all right for foster/adopt parents to show their anger, too, as long as it does not degenerate into physical violence or personal demeaning.
Crying is okay. I remember when my mother phoned to tell me my father had two major heart attacks and was not expected to live. I dropped the phone, began to cry and raced around the house frantically to prepare for a quick trip to Chicago. My children were dumbfounded. They had never seen me cry. They responded immediately to my requests for cards to give grandpa. My relationship with my children deepened. And my father recovered.
Therapists can teach parents to use “I” messages. For example: “I am upset with what you have done. I want you to come here and sit next to me for five minutes.” Putting parental emotions into words can help the RAD child recognize his or her own feelings. Parents should avoid starting sentences with “you.” This suggests that the parent knows what is going on inside the child. Further, it implies an accusation which the child will probably deny.
Accentuate the positive. People are known to say, “What’s the matter with her? The more I get after her, the worse she gets…She’s just doing it to get attention.” Of course she is. Here is another obvious fact. Attention, whether positive or negative, is a payoff. Parents will get more of whatever they pay attention to. Every teacher, parent and supervisor knows this.
The therapist needs to teach parents to brainstorm with each other about times when their child relates personally with others. This is an important way to share awareness about incidents worthy of notice. Pick any event when the child interacts with a companion. When he or she joins a club, has a friend over or plays with a pet. Especially be aware of incidents such as joining with the family in conversation or action or resolving an argument without a fight. Then reward these moments by responding with a comment or a touch. “I’m glad to see you and Nicole together.” “I am glad you came with us…” Parents need to pay attention to these breakthroughs.
Expect misbehavior. Misbehavior may be problematic but it is, nevertheless, a relationship. Misbehaving is a step forward, away from being a loner and into the real world of other people. On the road back to normalcy, RAD children may be disrespectful, lie, fight, steal, break things, and do much else to irritate the parent. They may try a parent’s patience to its limit.
The therapist needs to support and encourage parents as they deal with an unruly child. The therapist can show how to correct these behaviors without squelching the child. Avoid long lectures. Lectures give too much attention to misbehavior and rarely work. The therapist can suggest more appropriate ways to discipline than isolating the RAD child. Instead, focus directly on the lying and stealing and other uncivil behaviors.
If the child lies, the discipline might be to refuse to accept his word from then on. If he steals, search his room, pat him down before leaving for school, make him pay back what is pilfered. The goal is to skip the lecture, don’t focus on the bad behavior itself, and accomplish the desired outcome. The lies are stopped because the parents seek other sources for the truth. The stealing is handled because the parents take practical measures to uncover and recover what is stolen.
While misbehavior may be wearisome to the parents, the therapist can remind them that, for the RAD child, it may represent progress. The therapist should encourage them to respond personally and directly, without pushing the child away. Failure to attach is the predecessor of psychopathy, the lack of empathy or feeling for others. This is true moral retardation, far more serious than the more common misbehaviors of childhood. Parents might even become somewhat pleased that the child is testing them.
To truly help a child, the parent must go where the child “lives,” to the child’s personal world view. Giving moralistic admonitions to an RAD child is like the earlier example of trying to provide directions to a location without knowing where the potential traveler is starting from. With RAD, the starting point is a lack of empathy or emotion. To heal this, the therapist must help the parent to understand the emotional hurt and resultant anger that underlies the fear to love.
In summary, the therapist might say to the parent: Open your eyes to the obvious. Accept the real issues that circumscribe RAD. Then be patient. Don’t force things. Pass the tests. And most simply of all, just be there.
The assessment of bonding
In addition to the roles of diagnostician and therapist, the mental health professional may be asked to assess bonding. The nature of attachment is reasonably well elaborated in the psychological literature, in the guidelines of state welfare departments and by common sense. As noted in Chapter 2, however, the lack of a clear definition of bonding has led to a smorgasbord of unfocused data-gathering. Too often, assessments have used a variety of processes and techniques rather than focusing on bonding, its definition and its objective criteria.
The first and obvious step in conducting an assessment is to know what you are assessing. Then the evaluation must answer the simple question: Is this child bonded to these parents? To accomplish this, the bonding evaluator needs to obtain data relevant to the four operational definitions of bonding as listed in Chapter 3:
1) The length of time spent together
2) The behavior of the child
3) The reciprocal nature of the relationship
4) The perception of the larger community
Use a variety of sources. A thorough and professional evaluation of bonding will gather the necessary information about the child’s daily living from multiple areas using an assortment of techniques. Bonding is too important a factor to rely on a single approach.
Review all available documents, including the foster parents’ journal, child welfare records, court documents, reports from physicians, therapists, and other people with relevant knowledge. In addition to pinpointing the time in the foster/adopt home, these documents and reports should provide information related to the other objective definitions of bonding.
Obtain collateral information from extended family members, neighbors, babysitters, teachers and any others who might have had the opportunity to observe the child with this family. Is the child perceived as a member of the family? The wisdom of the larger community is one valid way to assess bonding.
A detailed written developmental history provided by the foster parents will offer data on the child’s growth and development, as well as the child’s behavior, family situation and other circumstances. The history can also be offered as evidence on how well the foster/adopt parents know the child, an important demonstration of the reciprocal definition of bonding.
Establish a developmental age. A measure of the child’s developmental age can be important to document the child’s special needs that would qualify the family for post-adoption subsidies. Equally important, when compared with the child’s development at the time of placement, the developmental age can be used to document the child’s progress while in the foster/adopt home. The Vineland Social Maturity Scale is one acceptable test to establish a developmental age. Other equally good checklists and test instruments are available for this purpose. If the child seems to be doing well in the current placement, a strong argument can be made in court to let well enough alone.
Child behaviors can be documented by various instruments and research-based checklists that demonstrate bonding. Many checklists exist to provide a good review of those behaviors that research has identified to indicate bonding. Two good examples are the Randolph Attachment Disorder Questionnaire[1] and Keck’s list of attachment disorders from the Ohio Attachment and Bonding Center.[2] A summary of child behaviors that may indicate the presence or absence of bonding follows.
Universal Bonding Checklist
(You can download this checklist from the following URL: www.adoptioninchildtime.org/abdownloads)
Place the appropriate number before each listed behavior in the space provided. This data is for clinical consideration only. No cumulative score is intended.
None = 0 Some = 1 A Lot = 2
Positive Infant Bonding Indicators (6 to 18 months)
___ Alert Appearance
___ Responds to caregiver’s voice
___ Vocalizes frequently
___ Shows age-appropriate motor skills
___ Likes to be cuddled
___ Can be easily comforted by caregiver
___ Sleeps well
___ Eats well
___ Prefers primary caregiver over others
Negative Infant Bonding Indicators (6 to 18 months)
___ Cries or is fussy most of the time
___ Resistant to comforting
___ Overly demanding
___ Delayed developmental milestones
___ Stiffens or is rigid when held
___ Flat or empty emotion
___ Lacks age-appropriate motor skills
Positive Pre-School Indicators (18-60 months)
___ Explores surroundings
___ Enjoys hugs and physical contact with main
caregivers
___ Copies mannerisms of main caregivers
___ Physical development at age-appropriate levels
___ Makes eye contact
___ Shows responses to separation from caregivers
___ Able to set limits on own behavior (age 3+)
___ Shows some understanding of how others feel
___ Comfortable enough to get in and out of caregiver’s
lap
Negative Pre-School Indicators (18-60 months)
___ Resistant to comforting and nurturing
___ Fails to imitate behavior
___ Overly affectionate to strangers
___ Does not appear relaxed or happy
___ Fails to show normal fears
Positive Bonding Indicators in School-Age Children (5-12)
___ Makes eye contact appropriately
___ Comfortable around primary caregivers
___ Gets along with friends
___ Shows appropriate responses to situations
___ Avoids self-harm and dangerous situations
___ Accepts comfort when in pain
___ Plays with peers without hurting them
___ Understands consequences of bad behavior
___ Sees self as a member of the family
___ Perceived by friends, school and neighbors as a
member of the caregiver’s family
Negative Bonding Indicators in School-Age Children
(5-12)
___ Fails to make eye contact
___ Cruel to animals
___ Destroys property
___ Steals
___ Poor relationships with peers
___ Lies about things that are obvious
___ Makes inappropriate demands
___ Overly dependent or clingy
___ Few or no friends
Projective techniques can be introduced to elicit emotions below the surface. The child is presented with a neutral but stimulating object or task and asked to respond. Because the stimulus admits of many possible variations, the child must complete the task in his or her own unique way. The evaluator should present materials that elicit responses about relationships and personal connections.
- a) Drawings are a popular procedure. One simple technique is to request a series of three drawings with no leading hints. The child is asked to: “Draw Anything. Draw a Whole Person. Draw Your Family.” In that order. Obviously, it is of interest whom the child places in his or her family and who is next to whom. Drawings could also be requested to show the child interacting with siblings or with any and all of the significant adults.
- b) Stories are also helpful. The evaluator may suggest a family theme. Or show the child evocative pictures about relationships and request imaginative stories. Magazine ads that suggest attachment and family issues might be used to stimulate stories.
- c) Sentence completion tests are frequently used to extract hidden feelings. The evaluator asks the child to complete a series of neutral phrases. The half-sentences should reflect the evaluator’s desire to learn more about the child’s relationships. Opening fragments such as: “I am…,” “I am afraid…,” “I am happy when…,” “I wish;,” “My family is…,” “I don’t care…,” “My dad…,” “My mom…”
The possibilities for encouraging useful information about the child’s ability to connect are limited only by the imagination of the evaluator.
First-hand observation of the child in the presence of the foster/adopt family is essential. The evaluator might meet with the entire family for several hours in the evaluator’s office playroom. While discussing the situation with family members, the evaluator has the opportunity to observe the interactions between the child and family members in free play. A visit to the home is even more informative.
A semi-structured dyadic interview can be quite helpful by moving beyond free play. Stokes and Strothman[3] routinely set some specific parent-child tasks. The parent may be asked to groom the child, to teach the child something new, to share a small meal, to leave and come back, to play a game together, to discuss something important or difficult, to make up a story together, to plan an activity together, and so on. The evaluator then has the opportunity to observe what happens in specific situations.
Write a strong report
As any good chef will affirm, the presentation of a meal is almost as important as the food itself. The same is true for the write-up of a Bonding Assessment. Once the information has been collected, a clear and well-organized report should follow. Writing a good report and presenting the factual information in a concise and compelling way is the other half of an effective evaluation. The evaluator must take as much care to write a thorough report as he or she did to conduct the evaluation.
The welfare department and the court will make their decisions based in good part upon the written report. Judges read. The evaluator’s report should be available for the judge to review after his or her memory of the oral testimony may have faded. A well-documented, objective, fact-focused report to the court is very important.
A strong bonding assessment will have six parts. The report should begin with a brief statement of the problem, noting how long the child and this family have been together, and indicating that the family wishes to provide this child with a permanent home through adoption. A list of the materials reviewed and the procedures accomplished should follow in the methods section.
The section on results should define bonding, giving research support for the definition and sub-definitions. The four specific ways to define bonding mentioned in Chapter 3 should be listed followed by the relevant factual evidence obtained. Facts should be allowed to speak for themselves. Line up the facts as they support the four operational definitions of bonding.
- Time together: How long have the parents and child been living together?
- Behavior: What behaviors does the child show?
- Reciprocity: How do the parent and child interact? What long-term commitments are the parties willing to make to each other?
- Community perception: What does the community think?
The discussion section may contain the reflections of the evaluator. Opinion should be reserved for this section and kept separate from the facts. It should be made clear whether bonding has or has not occurred. If bonding has occurred, the anticipated consequences should be presented, telling what happens when bonded relationships are disrupted or severed. The younger the child, the more lasting and destructive the consequences of termination can be. Removing a child from a bonded relationship has been compared to the loss of a spouse, brain surgery or the death of a parent.
The written report should make clear the dramatic increase in childhood and adult psychiatric disorders following the loss of a bonded relationship. Reactive attachment disorder, developmental delay, oppositional defiant disorder, AD/HD and learning disorders have all been linked to disruptions of bonding and may occur soon after such a loss. Sometimes, however, the impact is delayed and shows up in later life with an increase in the likelihood of adult mental illness, homelessness, crime and poverty. To support any anticipated outcomes, research and current statistics should be offered.
Summary
The role of the mental health professional is to diagnose and treat social and emotional problems. In addition, he or she may be called upon to perform a bonding assessment. A strong written report will define bonding and detail the serious consequences that may occur when such a significant relationship is interrupted.
Next, we consider the roles of the welfare department, the special advocates and the courts, those institutions that are entrusted by society to watch out for foster children.
Chapter 13 The Role of the Mental Health Professional Notes
[1] Elizabeth Randolph, “Randolph Attachment Disorder Questionnaire,” Evergreen, CO: The Attachment Center Press, 1997.
[2] The Ohio Bonding and Attachment Center. See the symptom checklists under “What is attachment?”
[3] John C. Stokes and Linda J. Strothman, “The use of bonding studies in child welfare permanency planning,” Child & Adolescent Social Work Journal, Vol. 13(4), Aug. 1996.