Promoting Healthy Sexuality After Sexual Abuse

By Dave Ziegler, Ph.D.

(The following article is dedicated to a friend and colleague Jan Hindman, who enriched the field of sexuality and trauma treatment before her untimely death in 2007)

I need to make you uncomfortable for a bit, but it is for your own good and the good of the sexually abused child you are trying to raise.  I say this because I need to talk about S..E..X., the most difficult topic for nearly everyone to talk about.  But the problem is that we have to talk about it if we want to raise a sexually healthy child.  Why human sexuality is so difficult to talk about in polite company is a topic for another day, but our starting place is that most of us would rather face any other issue than sexual issues with our children.

If you have a sexually abused child in your home that you are trying to parent, then you have a challenge on your hands that not even the experts have been willing to directly address—how does a parent promote healthy sexuality for a child who has already had sexual experience in the form of abuse?  If you have attempted to find some good books on the topic, which you probably haven’t, you found that there are none.  Yes, you heard me correctly; there are many good books on most every topic related to sexuality except how the help a child develop a healthy view of sexuality after the very unfortunate experience of sexual abuse.   In part this is an oversight, but even more so this lack of resources for parents is symbolic of our collective cultural neurosis that the less said about sex the better (unless the task involves advertising).

I want to begin our discussion with a quote from my friend Jan Hindman who wrote in her last book, “Of course we love our children.  We teach them what they need to know.  But when it comes to sex, we do nothing and hope the Sex Fairy will zap them in the crotch when they walk down the aisle to get married and magically, they will turn into sexually healthy adults” (Hindman, 2006).  This quote sums it up pretty well for our culture.  We avoid sex education because it might encourage children to act in sexual ways.  We put off talking to our children about sex, “until they are old enough to handle it,” meaning when the child is seventeen and has learned all they needed to know from other sources such as peers or the media (both excellent sources of healthy sexual information, right?).

The principle barrier to our culture helping children to become sexuality healthy is that we deny the fact that children are sexual beings.  We have body parts that perform a myriad of functions, but it is only the sexual body parts of our children that we hope will lie dormant in the dark recesses of their bodies only to awaken with enthusiasm on their wedding night. Enough said about how messed up our culture and most of us are regarding sexuality, we need to change the focus to discuss how we can help sexually abused children have a chance at a life that moves sex from a curse to a blessing.

I have started our discussion this way because we cannot give to a child what we do not possess ourselves.  If we want to raise a sexually healthy child we need to have some measure of healthy sexuality ourselves.  If we want our children to have some comfort with the topic of sex then we must model comfort.  Alright, you may have to fake it a little.  But seriously, we need to start the process by looking inward at ourselves.  Consider the following questions and how you would rate yourself:

  1. Do I live in a way to acknowledge that I am a sexual being?
  2. Am I comfortable with my own sexuality?
  3. Do I value and respect this important part of who I am?
  4. Am I aware of the important part my sexuality plays in forming who I am?
  5. Do I act in harmony with my sexual beliefs?
  6. Am I respectful of the above in others?

As you read further, you will see that respect will be a cornerstone of our journey.  Few of us are statements of full health so we all have to start where we are.  However, we need to realize that with the difficult road ahead we need to first acknowledge, respect and value our own sexuality if we are to impart healthy sexuality with our child.  Here are a few general suggestions from the Advocates for Youth when it comes to addressing sex with all children:

  • Examine your own beliefs and values before teaching a child.
  • Assert your own personal privacy boundaries; decline to discuss private sexual behavior with the child.
  • Use accurate language for body parts and functions.
  • Discuss sexuality at times that work best for connecting with your child.
  • Clarify relationships and how people are related to others.
  • Use photos, pictures, and visual materials.
  • Use teachable moments that come up in daily life.
  • Be honest in answering questions.
  • Value the child’s feelings and experience.
  • Offer praise and support.
  • Repeat information over time as needed.
  • Take advantage of available resources.

One of the ways we discourage rather than promote healthy sexuality in children is to deny their sexual interest and curiosity.  Take a moment and ask yourself the following question–since my child is a sexual being what are the ways he or she can appropriately express this sexuality? We all know many ways children can be sexually inappropriate, but are there appropriate sexual expressions in your home?  If there are none, like most families, then you fit right into the prevailing culture, but your child will remain confused about sexual thoughts, feelings and behavior both internally and with others they encounter.  Remember that most sexually abused children have a heightened interest and sensitivity to sex, even if you don’t hear about it you can trust that there is a lot going on inside the child’s biggest sex organ—the brain.

Promoting healthy sexuality is more than a two-week plan of action and hoping your job is done.  Sexuality will come into play at every developmental age of the child.  The older the child gets the more complex it becomes, and the more vulnerable you will have to be to model being an “ask-able parent.” This meaning someone the child knows he or she can go to for answers to their questions and receive support for their confused feelings.  The child will know you can be approached because of the many times you approach them first on this topic (I know this is not your favorite discussion topic, so to get some practice give your mother-in-law a call and have a sexual conversation, or if you prefer then call a friend).

So armed with as much internal comfort as we can muster and ready to take the next step, where do we go from here?  I would suggest relying on some suggestions from Jan Hindman’s book There is No Sex Fairy To Protect Our Children From Becoming Sexual Abusers (Hindman, 2006) or what she calls the Ten Commandments of raising sexually respectful children:

  1. Start young to teach biology as well as respect.
  2. Communicate–Children are learning from many sources, they need to learn from you.
  3. Teach logic–rules, robbery, and rescue.  Everything in life has rules that need to be followed. Do not let someone take something precious from you against your will, and remember to always ask for help when you need it.
  4. Don’t keep children from the world–teach children healthy information and critical thinking.
  5. Teach gender equality and the meaning of consent.
  6. Sexual respect goes beyond biology and nature. Respect is not automatically learned.
  7. People don’t end up bad if bad things are done to them. Teach resiliency and personal responsibility.
  8. Teach delaying gratification and self-esteem.
  9. Teach RESPECT—the vulnerability of others, healthy guilt, restitution, the feelings of others, and anti-bullying.
  10. Teach touching and tenderness through your modeling at all ages.

As you are probably aware, sexual abuse can distort a child’s interest and curiosity.  Although not all interest in sex is a sign of pathology, in the same way not all interest in sex is normal and natural.  Therefore you as the parent must distinguish between healthy and unhealthy interests along with thoughts, feelings and sexual behavior.  Fortunately there are some resources in this area.  One is my own measure called the Inappropriate Sexual Behavior Scale, which can be found in my book Raising Children Who Refuse To Be Raised (Ziegler, 2000). Another resource is the booklet Understanding Children’s Sexual Behaviors (Cavanaugh Johnson, 2004). Both resources can help you distinguish from a wide range of healthy and unhealthy sexual themes in children.

Example of unhealthy themes that point to concern are the following: preoccupation with sex, sex play with much younger children, precocious knowledge beyond the child’s age, unusual sexual interests, drive to act out sexually, sex play that has a negative impact on other children, seeing others as sex objects, violating the rights and boundaries of others,  adult-like sexual activity, directing sexual behavior toward adults, sexual activity with animals, the use of sex to hurt others, bribery, threats, force to engage other children in sex play (Cavanaugh Johnson, 2004).

Now that your blood pressure was raised by the above list, some suggestions to handling sexual behavior may help calm you down.  The following are eight general principles for working with sexual behavior in all children:

  1. Remove the aura of sex and consider it as behavior, nothing more/nothing less.
  2. Work on being more comfortable talking about sexual issues.
  3. See the child and not just the behavior.
  4. Translate the meaning to the child of the sexual behavior, some sexual behavior is about attention not about sex.
  5. Consult with a partner, we often need a reality check when dealing with sexual behavior.
  6. Don’t minimize and don’t catastrophize.
  7. Don’t expect children not to be sexually curious at every age.
  8. Be sure to replace every problematic behavior with an alternative appropriate behavior.

Raising the sexually abused child can make your job even more difficult than the child who has not been abused. Sexual abuse often causes children to view sex as bad and yet they are attracted to it.  When adults view sexual themes as bad, this reinforces the problem. The answer to this dilemma is to transform sex into something positive.  Remember the goal is to promote healthy sexual interest, not stamp out all sexual interest.

Perhaps the most that can be done on this topic in a brief way is to provide a road map for the journey.  There will undoubtedly be some twists and turns along the way and a few surprises as well.  Here are some final practical suggestions to help guide you on this complex journey toward healthy sexuality for your child (and for you as well).

  • Go over rules of touching, space, and consent.
  • For young children use the language of playing games, “We don’t play the penis touching game in our home.”
  • Teach the child that our bodies are like our other important possessions, we care for them and protect them.
  • In teaching the child to be safe, he or she has already found the dangers, help the child learn how to determine the good from the bad.
  • Teach critical thinking, “In the story I just told you who was right and who was wrong?”
  • Talk to the child about the dangers in the world and how to avoid them, don’t pretend they are not there.
  • Explain to the child the people and places to avoid and why. Don’t teach fear, explain the hazards.
  • Your home must be an environment of respect in all areas.
  • Respect starts with people and objects then moves to sexuality.
  • You must specifically teach respecting boundaries to children who have had their private space violated.
  • Help children separate who they are from what was done to them.
  • Realize that many abused children have negative views of self and the future, you need to help them alter these views.
  • Teach children how to bounce back from adversity not only with sexual abuse but with all challenges in life.
  • Point out when the child overcomes difficult challenges and reinforce these small successes.
  • Responsibility must be specifically taught, it does not come naturally.
  • Sexuality is an extension of many aspects of life–respect, caring, intimacy, equality, and consideration.
  • Reframe the meaning of touch to include caring and loving touch.
  • Touch must be a communication of a positive message, not exploitation and abuse.

This has been a considerable amount of information in a few short pages and there is obviously a great deal more that could be said.  There is no quick and easy way to handle one of the most difficult aspects of the world’s most difficult job—parenting a healthy child, particularly when the child has been traumatized.  Becoming overly stressed will work against you, so do your best to relax and take it one step at a time.  The beauty of parenting is that there is little you can do wrong that can’t be fixed with time and effort.  There is no way to avoid the fact that parents must be the message they want their children to understand and internalize—teaching is fundamentally about modeling.  However, you are not expected to be an expert at either parenting the traumatized child or helping sexually abused children develop healthy sexuality.  In fact, there are no experts at this very challenging task, we are all early explorers of a complex and uncharted terrain.  Along the way make sure you take advantage of your personal support system and do not be reluctant to ask for help and some directions from time to time.  And good luck on your pioneering journey, both you and your child will gain from your efforts.

_______________________________

Advocates for Youth.  Sex Education for Physically, Emotionally, and Mentally Challenged Youthhttp://www.advocatesforyouth.org.

Cavanaugh Johnson, T.  (2004).  Understanding Children’s Sexual Behaviors.  What’s Natural and Healthy.  San Diego:  Family Violence and Sexual Assault Institute.

Hindman, J.  (2006).   There is No Sex Fairy To Protect Our Children from Becoming Sexual Abusers.  Lincoln City, OR: AlexAndria Associates.

Ziegler, D.L.  (2000).  Raising Children Who Refuse To Be Raised, Parenting skills and Therapy Interventions For The Most Difficult Children.  Phoenix: Acacia Publishing.

Understanding and Treating Attachment Problems in Children: What Went Wrong and How Problems Can Be Fixed

By Dave Ziegler, Ph.D.

This somewhat complex article reviews the basic tenets of traditional attachment theory and describes both its strengths and weaknesses. Revisions to attachment theory are suggested and detailed explanation is provided of both the causes and treatment of various types of attachment problems. It is both a technical road map and a practical guide to the journey.  Although complex, It has been written to be understandable to professionals and parents alike. (31 pages)   Link to full article here.

Adoption and Attachment

By Dave Ziegler, Ph.D.

 The Adoption Courtship Model

Out of necessity, Jasper Mountain Center (JMC) staff have attempted to isolate why some adoptions worked during the first five years of our program and why most didn’t.  The result of two years of considering this question has been the development and implementation of an adoption model for children who

  • are emotionally disturbed;
  • are hard to place; and/or
  • have single or multiple adoptive failures

The operating principles for our Adoption Courtship Model are the following:

  • Standard adoptive procedures are insufficient for special-needs children and their prospective families.
  • The odds are often against a successful adoption with these children, without preparation, training, and professional support.
  • The child and the family must be prepared for the reality of this adoptive relationship.
  • The adoption commitment must be made by both the child and the family and can only be made based on a relationship, not on information or interest.

The model has three phases:

  1. Phase I.  The child is prepared for the adoption by understanding his or her role in making it work or not work.  The child’s considerable power in the situation is made clear.  The family goes through the regular certification steps and is selected by the adoption committee.  The family meets with the caseworker and JMC staff to learn what to expect from the initial meeting.  The child is also prepared for this meeting.  The two sides meet with the caseworker and family therapist.  The child begins to build trust by getting to know the family as a unit, then the family members as individuals, and finally in the home environment.
  2. Phase II.  This is where the reality must begin to come in.  Both sides have an image of what they are doing and who they are doing it with, but it must become very clear and very real.  This phase is characterized by extended visits and family counseling.  The process starts with a focus on the strengths and positive attributes of both sides, moves to the faults and flaws of both sides, and finally underscores the realities of the combination of strengths and weaknesses of the adoption.
  3. Phase III.  There are three necessary commitments for the adoption to work.  The initial commitment on the part of both child and family is a commitment of interest, time and effort in regard to adoption.  The second is a commitment to relationships with the child, and the child to the family.  The final commitment is to family for life.  The last commitment is the final step in a successful adoption of special-needs children, not the first step as in regular adoptions.  This commitment must be made to a person, not a concept.  This is important for these children because the reality of how difficult adoption is with disturbed children must be stronger than the commitment to the adoption as a concept.

Suggestions and Techniques

PHASE I. 

Preparation.  Phase I starts long before the family and the child meet.  One of the keys here is preparation.  There is an important question to ask before the specific adoption work begins:  “Has everyone received some preparation for the adoption?”  Too often the family receives more preparation than the child.  Preparing the child for an adoptive placement should ideally begin a year prior to meeting family, with specific counseling on the issues that will come up.  Along with adoption classes, it is valuable to have the prospective parents meet with the adoption worker or counselor who will work with the transition process to prepare the family for the probable struggles that are ahead.

Initial meeting.  After the adoption committee gives its blessing to a match and the Adoption Courtship Model is decided on, it is then important for the family to meet with the adoption worker(s) and the counselor who will provide the transition counseling and discuss the model, the process, and the goals.  Keep in mind that most adoptive families are in a mild to huge rush to have the child.  A rushed courtship is almost always problematic.  Gain the family’s agreement and commitment to the process or don’t use this model (in general, the bigger the rush the family is in, the more concerns there are about their readiness).

The initial meeting of child and family.  Again the suggestion is for the worker(s) and counselor to be actively involved.  Often for this population, meeting the parents alone before children are involved is less complex and overwhelming for the adoptive child.  There should be informal time between the child and the parents, as well as the worker and counselor outlining what will be happening over the next few months and why.  Keep the meeting from being stuffy or too formal.  Make it clear that the goal is to see if in the long run this is a good match for everyone concerned.  All sides will have a voice (empower the child to influence his or her future and you will have a much better response).

Process.  Start with meetings in counseling to get to know each other.  Have the whole family come the second time.  Use techniques to rapidly point out the different personalities in the family (who is the clown, who is grumpy in the morning, etc.)  A technique here is to have the members of the family write on a sheet of paper the things they like and dislike about the family member to their left and right.  The counselor reads the items and has the family guess whom it was written about.  Start with afternoon visits away from the family home.  Go to daylong visits and then an overnight visit, again away from the family home.  This is to equalize the playing field.  In the family home only the adoptive child is unfamiliar with the environment.  In a park, restaurant, or motel at the beach, the focus is on the relationships, not on getting used to the family’s turf.  The adoptive child should have a chance to get to know all family members at least a little, both individually and together, before going to the family home.

Counseling.  The initial meetings and discussions should take place in the counselor’s office.  After each visit there should be a session.  The counselor plays the role of bringing the family and child together and facilitating the process so both sides know that the situation is organized and under control.

PHASE II.

Counseling.  Counseling continues to be frequent but not necessarily occurring each time.  Involve foster care providers to help make the child’s strengths and weaknesses clear.

Process.  GET REAL!  Arrange extended visits, primarily in the home environment.  Get away from special events and get down to everyday life.  The goal of this phase is to make it clear what this adoptive combination will really be like.

Techniques.  Stress the strengths and weaknesses of the match, the family, and the child.  It may be difficult or embarrassing, but it is time to air everyone’s strong points as well as dirty laundry.  Use techniques like having everyone answer such questions as “When I get really angry, I …,” “I show sadness by …,” “When I am grumpy, the best way to deal with me is …,” etc.  Role-play some of this.  Have children act like Mom in the morning before coffee.  How do the parents fight with each other?  Have the adoptive child act out some of his less impressive qualities, such as being rude, disrespectful or hurtful.  Whatever family members will see later should be talked about, even acted out, now.

PHASE III.

Process.  Now that everyone has met and should know a lot about one another, the emphasis shifts to commitments.  There are three levels of commitment:  (1) time and effort, (2) relationship, and (3) life commitment.  Commitment 1 should have long since been made and operationalized.  It will be important to review and evaluate how everyone has handled this commitment because it will be an indicator of the next two.  How interested is everyone in a commitment to relationship?  In the case of attachment-disordered children, this must be reviewed carefully to have realistic expectations.  It is clearly time to begin putting out on the table the issue of life-long commitment.  Again, the commitment must be to people, not to the concept of adoption.

Counseling.  Here is where the skill of the counselor is most needed.  There is much complexity in commitments.  There may be resistance on everyone’s part to addressing this.  If things are going smoothly, why upset the apple cart?  No one really wants the final analysis to be halting the adoption because it is not overall a good match, but this may be the case.  The counselor must be firm and willing to be the bad guy.  The capacity of the child to commit himself may be problematic, and the parents may have better intentions than abilities.

Ritual.  If the adoption gets a green light, then some have found a formal recognition of the adoptive commitment an important step.  Consider having a ceremony.  Invite friends and throw a party.  Our culture does this for most important events.

A Final Thought

Adoptions can work with special-needs children, but the work is never completed (yet when is any parent’s job done?).  Despite an excellent placement for both the child and the family, the work has only begun.  The transition into the home will set an all-important tone, but don’t fool yourself that the job will get easier.  Our experience is that new struggles come up with each physical and developmental stage of the child.  But that just makes adoption like life—a new challenge around every corner.

Appropriate and Effective Use of Psychiatric Residential Treatment Services

By Dave Ziegler, Ph.D. 

Executive Summary 

Stakeholders in a comprehensive system of care view psychiatric residential treatment as a dynamic and critical component interfacing with an effective overall mental health system for children (Butler & McPherson, 2006).  To be most effective PRTS must be targeted, responsive, and individualized to the needs of the child and the family and have the following characteristics: 

  • Integrated into the overall system of care and includes a continuum of step-up and step- down services within the same provider organization.
  • Offers a comprehensive and ecological model of multi-model treatment interventions into an integrated whole, designed to meet the individual needs of a child and the child’s family.
  • Commitment to national standards of excellence, a continuous commitment to quality improvement, and have an identifiable treatment philosophy and approach based upon research and empirical evidence.
  • Emphasizes the environment around the child that will necessitate family interventions, partnering with families during and after residential services to best meet the child’s needs.
  • Makes an impact on the child’s positive thoughts and perceptions, emotional self-regulation, and pro-social skills and behaviors.

Psychiatric residential treatment services can play several effective roles within the overall system including: a. intensive treatment while maintaining safety, b. a component of a step up/step down plan for a child, c. Treatment of serious disorders that require coordinated multimodal interventions, d. assessing medication level while providing a stabilizing environment, e. alternative to psychiatric hospitalization, and f. a treatment of last resort for children for whom other interventions have been ineffective. 

Less appropriate uses of PRTS include: a holding place for a child waiting for a community placement, destabilizing the child by rapidly altering medications or delving into deeper psychological states without sufficient time to re-stabilize, and when the length of time in PRTS is predetermined before admission due to cost, utilization, or other factors unrelated to the needs of the child. 

The commonly repeated criticisms concerning the lack of research support for the effectiveness of PRTS lack validity.  The comprehensive nature of a multimodal integrated environment presents unusual challenges for isolating variables for causal research.  However, considerable research exists to support the overall effectiveness and efficacy of PRTS. 

When efforts are made to insure that the proper children are admitted to well designed PRTS, the child, the family, and the system of care can expect individualized, client-centered care that can result in positive outcomes for everyone. 

Introduction–Efficacy and Effectiveness of PRTS 

A common goal among all stakeholders in the system of care for children is to develop a comprehensive array of services that is sensitive to the needs of children and their families and provides needed care on a continuum of intensity based upon individualized needs.  For over fifty years there has been a debate concerning putting children in out-of-home placements.  The debate has continued whether this it is the orphan asylum of the past or the psychiatric residential treatment center of the present.  For a variety of reasons, some well deserved, residential care has been plagued by negative stereotypes and pessimistic sentiments (Frensch & Cameron, 2002). A persistent notion that institutional life is contrary to a child’s nature (Whittaker, 2004) has led to “an archaic and inaccurate perception of residential treatment as a single type of ineffective, institutional congregate care for children” (Butler & McPherson, 2006). However, the long standing debate over residential settings has gradually given way to an acknowledgement that the best system of care includes alternatives for the needs of all children regardless of the level of required intensity (Leichtman, 2006; Butler & McPherson, 2006; Lieberman, 2004).  Therefore the question has changed from whether residential treatment should used, to what is the appropriate and effective use of residential treatment in the new system of care. 

There is considerable literature and research support for the value of residential treatment of a broad variety of types and approaches, particularly for the sophisticated treatment settings that have met the highest national standards of excellence (CWLA, 2004; Lewis, 2004; Friman, 2000; Handweck, Field & Friman, 2001; Larzelere, Daly, Davis, Chmelka & Handwerk, 2004; Lipsey & Wilson, 1998; Lyman & Wilson, 1992; Pfeifer & Strelecki, 1990; U.S. Department of Health and Human Services, 1999). “Residential services are an important and integral component within the multiple systems of care and the continuum of services” (CWLA, 2005). This statement from the largest children’s advocacy organization in the country outlines the new thinking coming from policy makers, system managers, advocates, families, and providers.  The many arguments against the use of residential care of the past, including the comparison of one level of care over another, are out of favor due to improper comparisons and lumping divergent services (Handwerk, 2002; Butler & McPherson, 2006). In its place is a more inclusive and practically position that there will always be a number of youth who require the intensive structure and safety of the residential setting. Whether it is the Child Welfare League of America, the Building Bridges initiative, or the providers themselves (AACRC and others), there is wide support from stakeholders that residential care is an essential and important part of the overall system of care past, present and into the future. 

The psychiatric residential treatment program of today is not the same as programs of the past, including the very recent past.  This fact makes most comparisons to current care and the residential treatment of the past questionable in their validity.  The quality Psychiatric Residential Treatment program of today is not only integrated into the overall system of care, but includes a continuum of step-up and step-down services within the same provider organization.  Such an internal system of care allows for children and families to change levels of treatment intensity without changing key staff such as psychiatrists, therapists, teachers, and mentors.  For child with significant mental health needs, the level of treatment intensity will necessarily change over time if the plan of care is effective. 

What Constitutes Good Psychiatric Residential Treatment Services 

A quality residential program offers a comprehensive and ecological model (Stroul & Friedman, 1996; Wells, Wyatt & Hobfoll, 1991; Hooper, Murphy, Devaney & Hultman, 2000) of multi-model treatment interventions woven into an integrated whole, designed to meet the individual needs of a child and the child’s family.  The best programs start with a commitment to national standards of excellence, a continuous commitment to quality improvement, and have an identifiable treatment philosophy and approach based upon research and empirical evidence.  Effective programs will emphasize the environment around the child that will necessitate family interventions, partnering with families to best meet the child’s needs, and at times may include efforts to identify a family for children without one.  Good residential programs know the target populations that they are most effective with and have evidence based approaches for these populations.  Good programs make positively impacts on the child’s positive thoughts and perceptions, emotional self-regulation, and pro-social skills and behaviors.  The best residential programs are integrated into a community of stakeholders who have input into a continual unfolding of quality interventions in an overall environment of safety, respect and effectiveness. 

The Best Use of Residential Treatment 

For too long residential treatment has been relegated primarily to the placement of last resort.  In some situations it may be the case that a child has been unresponsive to treatment that is less intense or insufficiently environmentally integrated, thus necessitating the strengths of a residential setting.  The use of residential care as a “last resort” is still a possible role but there can be other roles as well: 

Intensive treatment while maintaining safety—Some children cannot be effectively and safely treated in a family setting.  Examples of this are serious violent behavior, firesetting, and significant sexual behavior. 

One component of an overall treatment continuum—At times the needs of a child may warrant treatment in a variety of settings from maximal to minimal levels of intensity as treatment progresses.  Residential care can be an important part of the plan including a back up to serious deterioration in levels of care in community settings. 

Treatment of serious disorders that require multimodal intervention—Children with the highest acuity of psychiatric needs often require a complex array of integrated services in a single setting.  An example of this are complex trauma disorders where up to a dozen specialized intervention strategies may be needed (Connor, Miller, Cunningham & Melloni, 2002). 

Safely assessing psychopharmacological intervention—A child may have serious emotional or behavioral destabilization when medications are significantly altered.  For children with several medications, it may be important to insure safety for the child and all concerned while the medication assessment process takes place. 

Alternative to hospitalization—A well designed psychiatric residential program can be an effective alternative to hospitalization for many serious children.  This can provide advantages including: keeping the child and family in the community, intensive care in a less restrictive setting, and a significant reduction in cost allowing a length of stay appropriate for the child. 

There are also ways that residential treatment should not be used.  It should not be a default setting for a child who has completed treatment but is waiting for a placement.  A residential setting should not be allowed to destabilize a child’s mental health, such as changing medications or opening painful psychological issues without sufficient time to follow through with the ramifications.  While there are children who have been shown in research to improve with short stays of six months or less in residential care (Blackman, Eustace, Chowdhury, 1991; Leichtman, Leichtman, Barker & Neese, 2001; Shapiro, Welker & Pierce, 1999), this is based upon a short-term approach of lowering the expectations of treatment through modest and selective goals such as primarily addressing the issue that caused the removal of he child from the family home (Leichtman & Leichtman, 1996).  However there is still a place for longer term treatment with specific childhood disorders that are not responsive to short-term interventions (Zegers, Schuengel, van IJzendoorn & Jansserns, 2006; McNeal, Handwerk, Field, Roberts, Soper, Huefner & Ringle, 2006; Greenbaum, Dedrick, Friedman, Kutash, Brown, Lardieri & Pugh, 1996).  Residential treatment is improperly used when the length of intensive residential treatment is predetermined before admission due to cost, utilization or other factor unrelated to the needs of the child. 

Efficacy and Effectiveness of Residential Treatment 

It is commonly stated that residential treatment has been shown not to be effective.  A closer look at efficacy and effectiveness tells a different story. While there have been weaknesses among the providers of residential care over the years, there have also been very effective services delivered in a residential setting.  This point raises an important distinction between an intervention and a setting.  Too often this distinction is misunderstood resulting in ‘apples and oranges’ comparisons (Butler & McPherson, 2006).  For example, an evidenced based intervention can be effective in a variety of settings, or the wrong evidence based intervention in a specific setting can be highly ineffective.  When discussing whether a placement is the best choice, both the setting and the interventions to be used are both important considerations. 

Science is informing the mental health world at an unprecedented pace.  Objective research is increasingly being considered to inform decision makers, parents and providers as to what to do more of, and what to discontinue.  Science considers all aspects of a situation to form an opinion, not just factors that confirm previous biases. Because there has been a fifty year debate over putting children in residential setting, both sides have presented data to enhance their argument, for or against. We must now move beyond previous biases and look toward objective science. 

Whether a treatment setting works depends upon both efficacy and effectiveness.  Objectively speaking there is research to support strong efficacy in residential care.  At the same time there are consistent questions as to the effectiveness reflected in research on residential treatment (Hair, 2005).  This apparent contradiction points to the difficulty in evaluating whether a complex setting works or not.  The answer often depends upon the way the question is framed, as well as how outcomes are measured.   

There has been decades of research evidence of efficacious treatment of children and adolescents in all settings.  When children who receive a broad variety of treatments are compared with control groups of children receiving no treatment, the treatment group is consistently superior with an effective size from .7 to .8 (Casey & Berman, 1985; Baer & Nietzel, 1991; Burns, Hoagwood & Mrazek, 1999; Grossman & Hughes, 1992; Hazelrigg, Cooper & Borduin, 1987; Kazdin, Siegel & Bass, 1990; Shadish, Montgomery, Wilson, Wilson, Bright & Okwumabua, 1993; Weisz, 1987; Weisz, Weisz, Han, Granger & Morton, 1995).  Some treatments and some settings have shown better results than others, but treatment efficacy research provides strong and consistent evidence that providing psychological treatment to child clients is much better than not doing so. 

Much has been made of the scarcity of causal research on residential treatment.  The reason that effectiveness research on residential settings has been either mixed or lacking is primarily due to the complex weave of multiple treatments in an ecological setting.  Such an enriched setting of multi-modal treatment variables is not conducive to empirical causal research.  Moreover, “the very characteristics that are likely to make (treatment) effective make them more difficult to describe and evaluate…numerous elements of family and agency life weave together with the therapeutic intervention and potentially decrease the chance of finding a positive treatment effect when there is one” (Hair, 2005). Butler and McPherson point out that this lack of empirical evidence in part is based upon the challenge of measuring what residential care does best.  They report gains such as:  enhanced safety, truancy reductions, consistent medication management, reduced hospitalizations, consistency, structure, caring and nurturing, limit setting, psychosocial support, self-esteem role modeling, time to self-reflect, and focus on mental health issues, all of which are invaluable to the child but are complicated to objectify and analyze. “Thus the literature does not actually reveal much helpful information” (Butler & McPherson, 2006). 

Some of the research showing marginal or no positive efficacy makes the conceptual error of comparing some new type of treatment intervention with the traditional treatment setting of residential care.  There are studies that indicate poor outcomes with residential care (Burns et.al., 1999; Greenbaum et.al., 1996; Friman, 2000; Ruhle, 2005).  Some of these studies again address a setting, not specific treatment interventions.  Research on essentially all settings can find poor outcomes (families, hospitals, foster care, schools, etc.). For example, while there is considerable evidence of effectiveness for some uses of family based treatment foster care, other uses have been found to be contraindicated (Farmer, Wagner, Burns & Richards, 2003), or less effective for some populations than residential care (Drais-Parrillo, 2005). Treatment settings in themselves do not insure effectiveness, this can only be done by quality interventions within a treatment setting.              

When treatment interventions are the subject of research residential settings the results often show strong improvement (Landsman, Groza, Tyler & Malone, 2001; Hooper et. al., 2000; Weiner & Kupermintz, 2001; Burns et.al., 1999).  Research has shown long-term maintenance of gains in clinical functioning, academic skills and peer relationships (Blackman, Eustace & Chowdhury, 1991; Joshi & Rosenberg, 1997; Wells, 1991). 

Two predictors of long-term positive outcomes deserve to be specifically mentioned.  The quality of the therapeutic relationship in therapy has been found to be one of the most important predictors of long-term success (Pfeifer & Strzelecki, 1990; Scholte & Van der Ploeg, 2000).  In a recent study on attachment representations, children in residential treatment improved in their forming secure attachments and decreasing their avoidance and hostile behavior.  However this finding was true only for children with longer stays in residential treatment.  The study reported, “When the duration of treatment is extended, the personal attachment backgrounds of clients and treatment staff increase in importance (Zegers, Schuengel, van IJzendoorn & Jansserns, 2006).  The other long-term predictor of success is positive outlook, life satisfaction and hopefulness.  In a 2006 study children in residential treatment increased their hopeful thinking and general well-being, while decreasing psychopathology (McNeal, Handwerk, Field, Roberts, Soper, Huefner & Ringle, 2006). Attitudinal and cognitive variables such as hope have been found to predict outcomes above and beyond psychopathology (Hagen, Myers & MacKintosh, 2005). This study on hope found the children with the highest levels of psychopathology made the most gains after 6 months of residential care. 

Therefore a quick statement on the general findings of research indicate: strong support for providing treatment services to child over no treatment, mixed results when evaluating the setting, and strong support for effectiveness with specific treatments in residential settings.  It can therefore be said that, in general, treatment provided to the child will be better than none at all, and it is the treatment interventions used in the residential setting that are the determining factor of efficacy and not the setting itself. 

The Right Target Population for Psychiatric Residential Treatment 

Intensive treatment services in a residential setting are restrictive and potent and should only be a part of the plan of care for a child if needed.  There is common agreement that care should be taken before placing a child out of a family setting and particularly when placing the child in a PRTS program.  It is important that guidelines exist concerning the right target population while not being so prescriptive that children ‘fall through the cracks.’  To avoid legislating children out of a needed service, it is essential that the individual child’s needs must come first, and the child matched to the proper level of care intensity.  The overall criteria for such a restrictive setting is to include only those children who cannot receive the treatment they need while remaining in a family setting.   The historical criteria for admission to PRTS have been: 

  1.  Other treatment resources available in the community do not meet the treatment needs of the child.
  2. Proper treatment of the child’s psychiatric condition requires services in a psychiatric residential treatment setting under the direction of the psychiatrist.
  3. The services can be reasonably expected to improve the child’s condition or prevent further regression so that psychiatric residential services may no longer be needed
  4. The child has a principal diagnosis of Axis I of a completed 5-Axis DSM diagnosis that is not solely a result of mental retardation or other developmental disabilities, epilepsy, drug abuse, or alcoholism. 

These criteria have provided guidelines while allowing for individual needs to be considered.  If proper treatment resources exist in the community, if the child does not need psychiatric oversight, if the treatment can help or prevent further deterioration and if they child has a mental health diagnosis, then the child can be considered.  As the system focuses on improving community resources, more children would be screened out due to the first criteria. 

The one screening tool that has been used in the past is the Childhood Acuity of Psychiatric Illness.  It has been used to inform the admission and discharge decisions but has not been the sole criteria.  Like the CASII, where it is possible to have an overall low acuity score yet be appropriate for intensive treatment due to high risk behavior, the CAPI scores do not address all areas of need or interest when making admission decisions.  Therefore it cannot be used solely as an indication of proper or improper placement decisions. 

There is general agreement that treatment should be individualized, strength-based, and integrated.  Therefore it is important to insure that admission and discharge decisions are individualized and not based upon a score or single or multiple indicators not related to the needs of the child. 

It is important that the child have a serious mental health issue to be appropriate for PRTS.  However, the treatment needs of the child should be the primary consideration and not the diagnostic category, which often varies by practitioner.  Frequently a child’s diagnosis changes when the provider changes.  Diagnostic categories are not discreet in many cases and children needing PRTS care typically have multiple Axis I diagnoses. The diagnosis of a child at admission has been found to be a negligible factor in success at discharge (Hair, 2005), thus the specific diagnosis should not be used as a factor to screen a child in or out of PRTS. For example, lf a child is dangerous due to a mental health diagnosis, the child should not be screened out due to which diagnosis the child has been given.  Using another example, if a child is suicidal and has a serious oppositional defiant diagnosis, the child should receive the treatment needed in a safe setting, which could necessitate a PRTS level of care, regardless of the diagnosis. 

Research consistently indicates that children with supportive families do better in general, do better in school, do better in treatment, and do better coming out of PRTS.  This makes logical sense.  However, true trauma informed care necessitates that a child who is unlucky enough to receive poor family support or who has lost his or her biological family, should not be further neglected by the system and prevented from receiving PRTS care if that is the indicated need.  Developing an aftercare resource becomes an important part of the plan of care.  Trauma informed care also requires that the treatment reflects the child’s past, provides effective trauma treatment, and insures safety, predictability, and stability of placement while intensive trauma treatment is provided.  For a seriously traumatized child, focusing solely on stabilizing a child’s behavior without providing intensive trauma treatment is not individualized, nor is it responsive to the needs of the child and family. 

Summary 

Psychiatric residential treatment is an important and essential component of the mental health system of care.  The best treatment programs are ecological in orientation and combine all the needed components to best help the child and family.  Despite the fact that ecological treatment settings are not conducive to quantitative causal research designs, they have been shown to be some of the most effective services for children with multiple needs.  Psychological treatment has shown decades of strong support across settings and has been shown effective when interventions in residential settings are considered rather than the setting itself.  The family must be involved in both decision making and intensive treatment along with the child.  If a child has lost his or her family for whatever reason, the child should not be further neglected by not receiving the level of intensive treatment services needed.  The right target population should be afforded PRTS.  Adhering to the historical criteria has shown that the right children receive the right level of care.  Reliance on any one score, instrument or factor alone is contraindicated for PRTS as it is for any placement decision for a child.  The admission decision on a child must be individualized with the needs of the family taken into consideration.  The treatment must conform to the child and family and not expect the child to conform to the treatment.  This includes both treatment programs as well as the overall system of care.  When a PRTS program is carefully designed with multi-modal treatments to address the complex needs of the child, and individualized in partnership with the family, this intervention can turn the most seriously challenging children in the system of care into some of the most improved consumers.  Such an outcome is one that is desirable to all stakeholders in the system of care.  

References 

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Burns, B.J., Hoagwood, K. & Mrazek, P.J.  (1999).  Effective treatment for mental disorders in children and adolescents.  Clinical Child and Family Review, 2, 199-254. 

Butler, L.S. & McPherson, P.M.  (2006).  Is Residential Treatment Misunderstood?  Journal of Child and Family Studies. 

Blackman, M., Eustace, J. & Chowdhury, T.  (1991).  Adolescent residential treatment:  A one to three year follow-up.  Canadian Journal of Psychiatry, 36, 472-479. 

Casey, R.J. & Berman, J.S. (1985). The outcome of psychotherapy with children.  Psychological Bulletin, 98, 388-400.  

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Drais-Parrillo, A.A.  (2005).  The Odyssey Project:  a descriptive and prospective study of children and youth in residential group care and therapeutic foster care.  Child Welfare League of America, Washington D.C. 

Farmer, E.M., Wagner, H.R., Burns, B. J. & Richards, J.T.  (2003) Treatment foster care in a system of care: Sequences and correlates of residential placement. Journal of Child and Family Studies, 12, 11-25. 

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Grossman, P.B. & Hughes, J.N.  (1992).  Self-control interventions with internalizing disorders:  A review and analyses.  School Psychology Review, 21, 229-245. 

Hair, H.J.  2005.  Outcomes for Children and Adolescents After Residential Treatment:  A Review of Research from 1993 to 2003.  Journal of Child and Family Studies (14), 4, 551-575.219. 

Hagen, K.A., Myers, B.J. & MacKintosh, V.H.  (2005).  Hope, social support, and behavioral problems in at-risk children.  American Journal of Orthopsychiatry, 75, 211-219. 

Handweck, M.L., Field, C. & Friman, P.C. (2001).  The iatrogenic effects of group intervention for anti-social youth:  Premature extrapolations?  Journal of Behavioral Education, 10, 223-238. 

Handwerk, M.L. (2002).  Least restrictive alternative: Challenging assumptions and further implications.  Children’s Services: Social Policy, Research & Practice, 5, 99-103. 

Hazelrigg, M.D., Cooper, H.M. & Borduin, C.M.  (1987).  Evaluating the effectiveness of family therapies: an integrative review and analysis.  Psychological Bulletin, 101, 428-442.  

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Joshi, P.K. & Rosenberg, L.A.  (1997).  Children’s behavioral response to residential treatment.  Journal of Clinical Psychology, 53, 567-573. 

Kazdin, A.E., Siegel, T.C. & Bass, D.  (1990).  Drawing on clinical practice to inform research on child and adolescent psycholtherapy: Survey to practitioners.  Professional Psychology: Research and Practice, 21, 189-198. 

Landsman, M.J., Groza, V., Tyler, M. & Malone, K.  (2001). Outcomes of family-centered residential treatment.  Child Welfare, 80, 351-379. 

Larzelere, R.E., Daly, D.L., Davis, J.L., Chmelka, M.B. & Handwerk, M.L.  (2004).  Outcome evaluation of the Birls and Boys Town Family Home Program.  Education & Treatment of Children, 27, 131-148. 

Leiberman, R.E. (2004). Future directions in residential treatment.  Child and Adolescent Psychiatric Clinics of North America, 13, 279-294. 

Leichtman, M.  (2006).  Residential treatment of children and adolescents:  Past, present and future.  American Journal of Orthopsychiatry, 76, 285-294. 

Leichtman, M. & Leichtman, M.L.  (1996).  A model of short-term residential treatment: General Principles and Changing Roles.  In W. Castro (Ed.), Contributions to residential treatment, 1996.  Alexandria, VA:  American Association of Children’s Residential Centers. 

Leichtman, M., Leichtman, M.L., Barker, C.B. & Neese, D.T.  (2001).  Effectiveness of intensive short-term residential treatment with severely disturbed adolescents.  American Journal of Orthopsychiatry, 71, 227-235. 

Lipsey, M.W. & Wilson, D. (1998).  Effective intervention for serious juvenile offenders:  A synthesis of research.  In R. Loeber & D.P. Farrington (Eds.), Serious & violent juvenile offenders: Risk factors and successful interventions.  Thousand Oaks, CA: Sage Publishing. 

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Lyman, R.D. & Wilson, D.R.  (1992).  Residential and inpatient treatment of emotionally disturbed children and adolescents.  In C.E. Walker & M.C. Roberts (Eds.), Handbook for clinical child psychology (2nd ed.),  Oxford, UK: Wiley Publishing. 

McNeal, R., Handwerk, M.L., Field, C.E., Roberts, M.C. Soper, S., Huefner, J.C. & Ringle, J.L. (2006).  Hope as an outcome variable among youth in a residential care setting.  American Journal of Orthopsychiatry, 76, 304-311. 

Pfeifer, S.I. & Strelecki, S.C. (1990).  Impatient psychiatric treatment of children and adolescents:  A review of outcome studies.  Journal of the American Academy of Child & Adolescent Psychiatry, 29, 847-853. 

Ruhle, D.M.  (2005).  Take care to do no harm:  Harmful interventions for youth problem behavior.  Professional Psychology: Research and Practice, 36(6), 618-625. 

Scholte, E.M. & Van der Ploeg, J.D.  (2000).  Exploring factors governing successful residential treatment of youngsters with serious behavioral difficulties:  Findings from a longitudinal study in Holland.  Childhood: A Global Journal of Child Research, 7, 129-153. 

Shadish, W.R., Montgomery, L.M., Wilson, P., Wilson, M.R., Bright, I & Okwumabua, T.  (1993). Effects of family and marital psychotherapies: A meta-analysis.  Journal of Consulting and Clinical Psychology, 61, 992-1002.  

Shapiro, J.P., Welker, C.J. & Pierce, J.L. (1999).  An evaluation of residential treatment for youth with mental health and delinquency-related problems.  Residential treatment for Children and Youth, 17, 33-48. 

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Zegers, A.M., Schuengel, C., van IJzendoorn, M.H. & Jansserns, J.M.  (2006).  Attachment representations of institutionalized adolescents and their professional caregivers:  Predicting the development of therapeutic relationships.  American Journal of Orthopsychiatry, 76, 325-334.

Surviving and Thriving in a Difficult Adoption

By Dave Ziegler, Ph.D.

Adoptions can be much like marriages:  Too many dissolve with pain for everyone; others stay together but everyone is unhappy; some get by with everyone lowering his or her expectations; and too few are a wonderful experience of loving, learning, and growing for all concerned.  To foster success, adoptions need as much care, thought, and skill training as marriages.  Marriages and adoptions fail partly because those involved do not know what they are actually saying yes to and discover they don’t have what it takes to handle the reality they find.  The goal becomes not only how to survive the reality of the adoption but how to thrive with the challenges involved. 

Maintaining More than Your Sanity 

Maintaining a healthy adoption can be compared to maintaining an automobile.  There are issues that need attention, and, as the ad goes, “You can pay me now or pay me later.”  Here are some comparisons:

Check the radiator                      Keep it cool, don’t overheat              
Check the steering/brakes       Stay in control at all times                   
Keep the battery charged         Keep your energy                              
Tune up for performance          Maintain your power                         
Check the plugs                         Keep your spark                             
Check wear on tires                  Realize you are wearing down before you burst. 

Contained in each of these suggestions is all you really need to know about maintaining health in an adoption.  The best truths are simple ones.  A recent best seller tells us that we learned in kindergarten everything we need for a happy, fulfilled life.  Well, some of us may have gotten it all the first time, but most of us could use a refresher.  If you got it all at first, then stop here.  But if you need to hear a bit more, read on. 

Why Do Adoptions Fail? 

There are many reasons for disrupted adoptions, but they all boil down to one overall issue.  Families choose to adopt for many reasons, but they want to do a good thing for all concerned.  Although they know there will be struggle, they do not adopt to put everyone through great pain.  Adoptions fail when a commitment to a child begins to harm commitments to other loved ones.  If it gets to the point that something has to go, it will probably be the adopted child.  There are two important perspectives here: 

The family.  There may be many reasons to adopt, but in the end a family decides it has room in its members’ lives and hearts for a new family member.  But what are they to do if their offers of love and affection are met with lack of interest or even hostility?  The family can understand that life may have been difficult for the child but believe all that can change if the child simply accepts the loving care of this new family.  After weeks and then months of a child letting the family know that he or she wants neither their home nor their heart, all that the adoption seems to be bringing everyone is pain.  Maybe the child would be better off somewhere else, and clearly the family members were better off before all this started.  This often becomes the final chapter, one filled with failure, guilt, and grief for everyone. 

The child.  All adopted children have experienced deep loss or they wouldn’t need a family.  Most special-needs children have experienced much more than loss.  Fearful and adrift in the foster care system, the child is informed that he will soon get a new family.  But do people realize what family may mean to the child—the ones that were supposed to always be there for you but weren’t?  To the child, Mom and Dad may mean someone who didn’t care, or worse, someone who was very abusive.  The child has probably been in numerous homes and schools.  Such children can’t put their heart on the line again unless they know it will be safe, so they test the family.  Sometimes their testing is misinterpreted by the family, and a negative cycle begins.  The worse it gets, the more fear arises and then more testing occurs.  The child begins to see the family stop trying and waits for the caseworker to appear and once again move the child from a home that was supposed to always be there for him or her but wasn’t.  This confirms again that the world is a cruel place where you have to fight to survive and avoid being vulnerable at all costs.  And the world has another antisocial personality. 

How can these traps be avoided?  How can the process not only last but be a good experience for everyone? 

What Successful Adoptions Look Like 

Successful adoptions involving a child with special needs tend to have a lot of TLC.  Tender loving care, you say?  Absolutely not!  Tender loving care is almost always in abundant supply in failed adoptions with these children.  That just may be one of the principal problems.  In this case TLC means something very different: 

T = Translating correctly what is really going on with the child in order to understand where the child really is.  It is commonly known that manipulative teenagers (and aren’t they all) talk in opposites.  It is often a safe bet to retranslate what they are saying to get closer to the truth.  Practice by retranslating the following:  I don’t want rules; I’m not worried about my future; I am all caught up on my schoolwork; I’ll be home early tonight.  This same principle works with special-needs children. 

L = Learning from the challenges of adopting a difficult child becomes one of the indicators of success, not how smooth it’s going for everyone.  If you want smooth, get some Jell-O.  But adopting is not smooth—it is trouble or challenge, depending on your point of view.  The more you see it as a challenge to learn from, the better the candidate you are to adopt a difficult child.   

C = Stay in control at all times in all situations involving the child.  These children did not get difficult on their own; they had lots of help from chaotic, abusive, and neglectful families that could not provide a safe or secure home.  Constant control sounds pretty heavy, but if you adopt one of these children, he or she will constantly test to see just how in control you are.  If the child is able to gain control, everyone loses; if the child can’t, everyone wins.  It’s that simple. 

TLC – Translating, Learning and Control – is easier said than done.  But here is part of the point – what does a difficult adoption offer you?  It offers an opportunity to grow yourself, as you give a deserving child a fresh chance to be part of a family. 

Seven Strategies for Success 

1.  Understand the real needs of the child.  It is not often helpful to listen to the child’s words or even to accept the child’s behavior at face value because of the opposite issue.  If the child has had an abusive or neglectful past, then his or her needs are pretty straight-forward despite the way the child acts.  These children need the following:            

  • Safety.  Will I be safe in a nonviolent environment where my basic needs will be met?           
  • Security.  I need a structured situation where a parent is in charge and I can just be a kid.           
  • Acceptance.  I need people who can accept me as a person even if they don’t like or accept my behavior.           
  • Belonging.  I need to belong to someone; I need to be connected to others and learn to give and receive affection.           
  • Trust.  I need to learn to trust and be trusted; I need to be treated fairly, with honest, to respect, and firmness.           
  • Relationship.  I need to be in relationships with others in a way that no one is victimized and both sides are enhanced.           
  • Self-awareness.  I need to learn how to make changes in my personality and behavior by self-understanding.           
  • Personal worth.  The final indicator of my being a success as a person is, Do I believe in myself and my own worth? 

2.  Positive discipline is the quickest route to your control and to the child’s personal worth.  Techniques include separate the child from the behavior; don’t punish—discipline (which means to teach); don’t let “time-outs” become a disguised punishment; use logical consequences; don’t ask the child to lie by asking questions you know the answer to; avoid power struggles; have the child fight with himself/herself, not with you; keep your sense of humor and don’t let the child decide what you will feel; and allow the child to change and be more responsible by not always locking the youngster into past behaviors. 

3.  Learn to win the manipulation game.  Don’t let the child use your rules against you.  Don’t be completely predictable to a manipulative child; you’ll become an easy target.  Keep the child off balance when he or she is trying to beat you.  In general, if the child is manipulating to get something, do your best to prevent the child from getting his or her way or you will get more manipulation (because it worked).  Stay a couple of steps ahead by predicting what the child might do and what you will do in return.  Don’t respond emotionally; you won’t think very creatively then.  Parenting is best done by a team; talk over your next move and get advice and ideas.  If the child has you on the run, the child will win the manipulation game and both of you will lose. 

4.  Get the help you need from the right source.  Quite frankly, some counselors who don’t understand these children can make the situation considerably worse.  It is not much of a challenge for a manipulative child to be “perfect” an hour a week in someone’s office.  If the counselor starts looking at you like you must be the problem, get someone else.  Ask prospective counselors about their experience with adoption, abused children, and kids with attachment problems.  Or better yet, go to a counselor who comes highly recommended for his or her skills with a child just like yours.   

5.  The only given is that this type of adoption will be difficult; it does not have to be terrible.  The difference is something you have complete control over – your feelings and sense of humor, the world just isn’t funny anymore,” and adoption is like that. 

6.  Make sure you are more than a parent.  If you are a parent twenty-four hours a day, you have become pretty dull.  Be a wife, a student, a hiker, a volunteer, a square dancer, an artist, a husband, or whatever, but don’t get stuck in the parent role where there is a whole lot more giving than receiving.  Batteries don’t last long if they never get recharged. 

7.  Don’t get in a hurry.  The saddest failed adoptions are the ones where the child is desperately testing and the parents call it off.  If only they could understand that the desperation is an indicator that the testing is nearly over and that they have almost passed the test.  It has taken a long time for these children to be hurt; it takes time for them to be vulnerable again.  But don’t continue down a road that is clearly leading nowhere.  Get some good help from a counselor who has a good road map – there may be a much better road to get where you want to go. 

Final Thoughts 

So what do you think?  If it sounds like a lot more work than you thought, don’t feel alone.  Just consider – if parents knew all they would have to endure with their birth children, would they be so eager to go through with it?  Make no mistake – parenting is the world’s most complex and difficult job.  It is even more challenging if you have to pick up the pieces that someone else has failed with.  If all this is more than you can imagine, then get a pet.  But if you want the ride of your life, if you want to be the most substantial influence in a young person’s life, and if you want to learn more about yourself than you thought was possible, then boy, does CSD have a deal for you!  

So You Have a Challenging Child in Your Home?

By Dave Ziegler, Ph.D.

Dave Ziegler is the founder and executive director of Jasper Mountain, a nationally recognized treatment program for traumatized children.  Dave is a psychologist and holds four professional licenses and has been a foster parent for many years.  In addition to his work at Jasper Mountain, he speaks throughout the country as well as internationally to parents and professionals.  Dave is the author of five books, including Raising Children Who Refuse To Be Raised, Traumatic Experience and the Brain, Beyond Healing: The Path To Personal Contentment After Trauma, and Neurological Reparative Therapy: A Roadmap to Healing Resiliency and Well-Being.  This article is drawn from his 2005 book Achieving Success With Impossible Children, Winning the Battle of Wills.

If you have a challenging child in your home, you are not alone.  With the numbers of children in foster care, the increased number of domestic and foreign-born adopted children, and children in biological homes that have experienced divorce and other domestic problems, parents today are searching for answers to the increasing challenges presented by troubled children.  Some of these children can make parents crazy, because parenting approaches that work for other children don’t help at all; and even worse, what worked with the child yesterday, doesn’t work today.  Sound familiar?

I know what you are thinking, “another one of those articles about being a good parent-with an expert saying: be consistent, stay calm and make sure the child gets plenty of tender loving care.”  Not so fast, in some cases this advice is a part of the problem rather than a part of the solution.  And if you haven’t already asked this, I will do it for you, “So what makes this guy an expert anyway?”  Good question.  There is only one thing that makes someone an expert in parenting difficult children and that is to have actually done it, and done it successfully.  Starting as a foster parent with one child at a time, my home has evolved into one of the top treatment centers in the United States. The type of children we go out of my way to help are those that refuse to ask for, or even accept, our attempts to help or to parent them.  Perhaps I have a screw loose, but I see these children as my best teachers.  So if your child is happy to see you when she comes home from school, if he volunteers to help out around the house for free and can be found on weekends cleaning his room while singing “Don’t Worry, Be Happy,” then this article is not for you.  I hear stories about such children, but I have never parented one.  My foster home turned into a group home, and then into a treatment center over the years.  But my family is still here 23 years later getting children who are grumpy (and worse) off to school each morning, and seeing if we can introduce each of them to a world they don’t believe exists-one where they can come out a winner.  Do they eventually get it?  Yes, in nearly every case.  But before they learn to touch the stars, they have to learn to firmly plant their feet on the ground.  If you are with me so far, then let’s get to work on parenting difficult children.

What I have found that works with troubled and difficult children is a combination of staying focused on the goal for each child, and knowing what I need to be doing more of, and what I need to be doing less of.  My goal is a progression of having each child experience the following and to do so in the correct order-experience safety, security, acceptance, belonging, trust, relationship, self-understanding and personal worth.  These critical components of being a successful human being must come one at a time as in stair steps, and rely on the foundation of the step that came before.  Without safety you can’t have security, without acceptance you cannot feel like you belong, and without trust you cannot have a successful relationship.  I ask myself what step I am on with each child I am working with and keep focused on the goal to get to the next step-one child and one situation at a time.

What I need to be doing more of can be broken down to the following: 1. Translate the child’s behavior and energy to understand what is going on inside of him (don’t get sucked into his words, works are seldom helpful), 2.  Give attention to things I want to see more of (don’t spend your day giving most of your energy to misbehavior, because what you give attention to, you get more of), and 3. Lead with thinking and not with emotions (don’t let the child decide how you are going to act or feel, remember that feelings are easy targets for children who want to wound others).

So what about being consistent, staying calm and tender loving care?  I find consistency overrated.  This is not the case with responsive children, because they need your consistency.  With troubled, angry and/or manipulative children, they will use your consistency against you.  To disrupt a child who gets stuck in the same negative behavior habits, I suggest creative inconsistency.  What this means is you must first disrupt the cycle between you and the child.  He is used to doing his thing (misbehavior) and waiting for you to do your thing (correcting the behavior).  You don’t like this cycle, but your child does like it because he feels in control of you and the environment.  If you are tired of this dance, then change it.  First short circuit the behavior pattern, and then intervene more effectively.  For example, if your bundle of joy has a habit of not liking dinner each night and colorfully sharing her culinary review, then start the dinner by saying, “Jessica, you only get dessert tonight when you have found something wrong with every aspect of tonight’s dinner.”  After the child looks up at you wondering, “Has she finally lost it?” she then has a dilemma (that I love to put children in)–do I follow directions and criticize, or do I refuse to criticize and break my pattern.  You win either way.  We call this prescribing the symptom, and it can also be called putting the child into a therapeutic bind.  The goal is not to frustrate the child, but the goal is to frustrate the behavior.

Most parenting classes will tell you to stay calm.  That is fine most of the time.  However, when I get ignored by children (this is frequent in the early stages), or if the child wants me to repeat essentially everything I say, I might try yelling my thoughts and directions.  I don’t do this in an angry way, just a loud way.  Troubled children do not like yelling in the house if the yelling isn’t coming from them, so they always ask me, “Why are you yelling?”  I tell the child that I am saving us both the time of either repeating or having them miss what I have to say.  When they ask me to stop it, I offer them a deal that I don’t need to yell if they listen and don’t need things repeated.  Welcome to the world of reciprocity.

As for tender loving care, the quickest way for a child to put a parent in the funny farm is to reject every overture of caring and love.  Love may have been all the Beatles needed, but they were not raising troubled children.  Difficult children need love all right, but it needs to come in the form of teaching the child the lesson that life and relationships are two-way streets, what we put out to others has a lot to say about what we get back.  So save your tender loving care until the child has moved beyond manipulation, self-hate and perpetual rudeness (yes, with the right steps they can move beyond these).  In the meantime give them a different type of TLC-Translating what is going on with them, Learning from every situation to be a better parent to this child, and staying in Control of your behavior, your emotions and the energy in your household.

With those basics as a foundation, let’s look at a number of strategies for successful parenting:

  • Take care of yourself-if you don’t do it, who will?  We all have rechargeable batteries, but like a flashlight, if we don’t take the time to recharge, our light becomes dim in a hurry.
  • See below the surface of behavior-what you can see is only a small part of the problem.  Behaviors are the result of what a child thinks and how he or she feels.  We must go deeper than managing behavior.
  • Be firm in a loving way-if we are too firm the child links us with past abuse, if we are too loving they may not respect us.  Strike a firm and friendly balance.
  • Never stop working on yourself-we all make mistakes parenting?  I use my mistakes as a model for children.  I admit the mistake and take personal responsibility, and then I take the necessary steps to repair any damage done.  How can we ask a child to do this if adults have not taught the child how by example?
  • Make sure the child feels your support-don’t wait until things go badly before showing your support.  When things do go badly, with every correction give the child the message you believe that he or she can do better.  “We don’t grab things from others just because we want it in this house.  I want you to think about this and I know you can come up with a better way to handle it.  When you do, let me know and you can have your turn.”
  • Always give more praise than criticism-criticism fits the child’s negative self-image, praise does not.  If you want the child to be more positive, he must hear more positive messages from you.
  • Practice the “New Day”-just because the child has been doing poorly in the past, start over each day and give them a chance to improve.  If the child is ready to move beyond misbehavior, make sure you are ready to let them.  This is one reason why extended consequences, such as grounding the child until age 21, are not recommended.
  • Don’t let the child lower your expectations-you generally get somewhat less than you expect from a difficult child.  If you expect a lot or a little, you will get somewhat less.  High or low expectations, its your call (by the way, the child prefers lower expectations).
  • Practice “No-Lose Parenting”-do your home work, use your superior mental skills, do your best, don’t give up, don’t expect an immediate return on your investment in the child, and remember, your responsibility is what you have become more so than who the child chooses to become.  If you do all this, how can you lose?

OK, so I haven’t told you everything you need to know to be successful with your difficult child.  Fair enough, so the little challenge in your home is going to take some extra study and work?  That is why this parenting approach has two textbooks with very appropriate titles:  Raising Children Who Refuse To Be Raised and Achieving Success With Impossible Children.  The ideas in these books can change the whole game with your child.  Working with tantrums, sexual behavior, lying and stealing, and teaching responsibility, positive discipline, are all covered in the style of this article. Obviously I believe the ideas will help you.  I believe this because the ideas were all taught to me not in graduate school but by the children I have parented.  Did I forget to say, parenting a difficult child can even be fun?  You will have to read more to find out about that (I warned you about my loose screws).  Happy parenting!