Articles on adoption, foster care, & pediatrics

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Help for the Holidays - Deborah Gray

Deborah Gray, MSW, MPA, author of Attaching in Adoption and Nurturing Adoptions and therapist extraordinaire, has shared a nice set of handouts for the holidays with us, reproduced here with kind permission. They're written for parents raising kids affected by histories of neglect, trauma, and anxiety. She has two slightly different versions, one for parenting kids with trauma histories, and one for children with anxiety. Good stuff to think about as a particularly stressful holiday season is upon us. I hope you find something helpful here, and we at the Center for Adoption Medicine send you happy and as-relaxing-as-they-can-be holiday wishes.

Friendships, Social Skills, and Adoption

In our practice we see a unfortunate number of children with friendship problems. It can be one of the more painful issues that arises for our clients. But there is also hope - some good resources are available to help children with social skills difficulties, and there is much that parents can do to help.

What we hear from some of our families is that their children “feel” younger than they are, and gravitate towards younger children, or are more drawn to adults than peers. It can be hard for them to “share” conversation; they may divulge too much personal information, or have difficulty finding interests in common. They may have trouble joining their classmates in play. They often lack a sense of how to be a good host when having friends over (controlling the play, etc). Boys may take things too far, getting too rough or out of control. Girls may be clingy or bossy. Children may not get invited to play-dates or parties, and may lack a good friend.

Childhood friendship problems is a topic that raises strong feelings in many adults. I don’t know anyone that had a perfectly socially successful childhood, and just reading the previous paragraph can bring up memories of loneliness and rejection. When we see our children having such difficulties it’s truly challenging to stay present and clear-minded about what’s going on. But it is important to find a balance of appropriate concern and involvement. Blaming the peer group, assuming things will be better in another school, or otherwise neglecting the issue isn’t helpful; neither is overreacting, anxious hovering in social situations, or trying to bribe or force other children to include your child.

Causes of Friendship Problems in Fostered and Adopted Kids

Social skills problems in the context of foster care and adoption have not been well-researched, but the causes likely lie in a combination of:

  • Lack of early secure attachments leading to more anxious/controlling behaviors in later relationships
  • Rough and unsupervised early interactions with peers
  • Poor social boundaries and judgement, difficulty reading others’ social cues
  • A higher prevalence of impulsivity, ADHD, and externalizing (acting-out) behavioral problems
  • Poor emotional regulation (quick to anger at perceived slights and rejection, etc)
  • Delayed social/emotional development
  • Challenges in social communication and language, making it hard to keep up with the increasingly fast-paced world of their peers

These risks are not shared by all of the adopted children that we see, but they are more common. In the world of social skills interventions, many of the participants are children (boys, usually) with ADHD, acting-out behavioral problems, or autistic spectrum issues. If you substitute "institutional autism", or general lack of appropriate formative social experiences, that's a combination of issues that fits many adopted and fostered children.

Patterns of Peer Problems 

The literature on social skills problems in general suggests that there are a few patterns of peer problems that are most worrisome, and deserving of intervention. Researchers in this field often categorize children by interviewing their peers to come up with how liked (or not) and influential they are. This all sounds a bit harsh, but no one knows better how children are doing socially than their peer group, and the categories that follow aren’t nearly as hurtful as peers can be. In this research context, children are grouped as:

  • Average (well-enough liked and influential)
  • Popular (desired as a friend and influential)
  • Neglected (not influential)
  • Controversial (both liked and disliked, also influential)
  • Rejected (disliked)

Interestingly, “popular” as derived from peer ratings is not the same as just asking who’s popular. The “sociometrically popular” kids are well-liked, good problem-solvers, and trustworthy - a good friend. The “popular kids” are actually seen as dominant and “stuck-up”. Neglected children may be shy or less motivated to join peers; they seem do well academically, and can start over in new groups and shed the “neglected” status. Controversial children are sociable but tend to use more social aggression and hostility; this also may not be a very stable category over time.

Rejected Children 

But the “rejected” group is the most concerning. Children with rejected status in one group tend to be rejected in new groups as well. Without intervention, they are likely to stay rejected over time, and are more likely to have later difficulties with delinquency and adult maladjustment.

Children who are classified by observers as socially withdrawn, plus rejected by peers (thus, not withdrawn by choice), are more likely to have internalizing problems like depression and anxiety. There are two sub-groupings of boys who are “rejected”: rejected plus aggressive (verbal aggression, rule-breaking, etc), and rejected with odd, immature, or “quirky” behaviors. The rejected-aggressive boys are more likely to have academic difficulties and ADHD. Girls have rates of rejection similar to that of boys, but are a lot less likely to be referred to social skills interventions; it may be that rejected boys stand out more and have more externalizing behaviors, while rejected girls have fewer overt problem behaviors.

If this sounds like your child, you should consider learning more about how to help your child with play dates and friendships (since you’ve got the potential to make a big positive impact), and explore local options for social skills groups. Here are a few tips, but the resources that follow will be more helpful:

Help your kids with the basics of social interactions

  • Teach your child learn appropriate social greetings-and-responses, and what degree of physical contact is appropriate for whom (how not to be a "space invader")
  • Encourage and model use of positive statements like praise and agreement
  • Help your kids learn to share a conversation (reciprocity)
  • Practice these skills over and over and over

Help children have frequent, successful play dates

  • For younger/less mature children, having shorter, more structured play dates can help
  • Practice being a good host beforehand, and come up with possible activities that their guest may enjoy
  • When it comes to games, emphasize shared fun over winning/losing, and "good sport" behaviors (make sure to model these as well!)
  • As a parent, stay aware of how things are going without hovering

Support your child in making and keeping friends

  • Make friends with neighbors with children, allow your kids to get to know each other
  • Get to know the parents of your kids potential friends (and enemies!)
  • Make your child's friends feel welcome in your home (greet them warmly, compliment them directly and to their parents when they pick them up)
  • Socialize across generations: make time for extended family, hang out with other entire families together, look for a range of ages for your child to get to know. Such shared family gatherings can provide models of interaction, unhurried time for children to get to know each other, and can keep parents in touch with how their kids are doing socially.

Help your children deal with the pain of rejection

  • Remember that some pain around peer issues is inevitable and a normal part of childhood; try not to overreact or get too caught up in your own issues
  • Don't nurture resentments, add fuel to feuds, or attempt to coerce other children into including your child
  • But do employ "active listening"; acknowledge and reflect back the emotions that you see your child having
  • Once your child feels heard and understood, help your child with self-soothing strategies like deep breathing, muscle relaxation, and active play
  • If bullying at school is involved, insist that it be appropriately addressed; most schools these days have policies, if not effective interventions, in place to deal with bullying
  • If your child falls into the "rejected status" category above, seek further help (see below)

Resources for Families 

One book for parents that I’ve really liked is “Best of Friends, Worst of Enemies: Understanding the Social Lives of Children”. Several of the tips above come from this book, which deftly summarizes the research about how children’s friendships evolve as they mature, and has solid suggestions for each developmental stage. Another book is "It's So Much Work to Be Your Friend: Helping the Child with Learning Disabilities Find Social Success". But having a good book probably isn’t enough for children that fall into the socially rejected category. That’s where social skills groups come in ...

Social Skills Interventions 

Social skills interventions for children do exist that have been well-studied, and show measurable improvements in parent and teacher ratings of social success. One such intervention is Children’s Friendship Training, which was developed at UCLA. Some of their work has specifically looked at children with ADHD, ODD (oppositional-defiant disorder), ASD (autistic spectrum disorders), and even FAS (fetal alcohol syndrome). I like this approach, as they’ve evaluated it with the types of problems my patients have, they have a rigorous approach to testing their program in general, and they include an important parent educational component which helps the gains children make in group generalize to the rest of their lives.

Your child's school may have a social skills group, and in the Seattle area there are several excellent private practice social skills interventions.

"Transforming the Difficult Child"

The following is an excerpt from Transforming the Difficult Child, by Howard Glasser and Jennifer Easley; reprinted with permission. I've posted this as a teaser, and because I really like the ideas in Chapter 2 (below) ... the actual techniques come later in the book.

As I've written elsewhere, this is my favorite book for parenting, and yes, transforming, children who are difficult to parent - intense, needy, having difficulty regulating their energy and behavior, "ADHD-ish", with negative self-image, acting out to get attention, and so on. Sound like any older adoptees you know and love? It's also a fabulous positive parenting approach for "easier" kids. Glasser's belief is that normal parenting and teaching methods are designed for the "average child", and that the harder normal methods are applied to difficult children, the worse the situation can get, despite the best of intentions.

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Tools for Assessing and Managing ADHD

The National Initiative for Children's Healthcare Quality (NICHQ) has developed a free toolkit for providers to help with standardized assessment and monitoring of ADHD (attention deficit/hyperactivity disorder) in children ages 6 and up, available from the NICHQ website.

ADHD is not a do-it-yourself-at-home sort of diagnosis, but I thought it would be helpful to make these available for completing before appointments, and there are excellent handouts here as well. You should not be filling these out if your child is less than school-age, or if you have a child who was only recently adopted in the past few months. Please bring these in to discuss with your health care provider if you have any concerns about ADHD, learning, or behavior.

Strengths & Difficulties Questionnaire

The Strengths and Difficulties Questionnaire (SDQ) is a well-done, brief (5 minutes), validated behavioral screening tool for 3-16 year olds that compares well to longer tools like the Child Behavior Checklist (CBCL/Achenbach). It can be completed and self-scored by parents, teachers, or adolescents themselves.

All versions of the SDQ ask about 25 attributes, some positive and others negative, in the domains of emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior. Questions also assess the impact of these problems at home, school, and with peers. Follow-up versions of the SDQ are available as well.

Even better, a free online version for parents of 4-16yo children can generate scores and interpretations for us, with linkage to book or website ideas, and some statistics on how likely a professional would be to find a "diagnosis" in a child with similar scores. The report comes in a "readable version", which has a neat "stressometer" graphic, likelihood of a diagnosis (appropriately, it does not actually diagnose your child), and overall impressions, with links to targeted book and websites. You can also view and print out a "technical version" with scoring to bring in to your providers, which can be very helpful at visits.

According to the authors:

"The information provided by parents is used to predict how likely a child is to have emotional, behavioral or concentration problems severe enough to warrant a diagnosis according to the ICD-10 or DSM-IV classifications. For each diagnostic grouping, there are three possible predictions: ‘low risk', ‘medium risk' and ‘high risk'. In general, these predictions agree fairly well with what an expert would say after a detailed assessment of the child. Around 25-60% of children who are rated as ‘high risk' do turn out to have the relevant diagnosis according to experts. So do around 10-15% of ‘medium risk' children but only about 1-4% of ‘low risk' children."

The authors have a nice page on "why bother with diagnoses". As for me, I'm a fan of picking up emotional/behavioral/attentional/social concerns promptly, and hope that parents and teachers of my patients will take advantage of this free and easy screening tool.

Like any screening tool relying on parent/teacher report it can be skewed by overly rosy, or more typically, overly negative feelings about a child. If you're seeing red, your child will score in the red - step away from the questionnaire ...

Also, a five-minute questionnaire is certainly not a substitute for professional evaluation, but can help you decide whether or not you might need to seek that help. Please bring your concerns and reports to us so that we can discuss what's going on and make appropriate interventions or referrals.

The "Difficult" Child

Some children, whether we blame temperament, genetics, neurochemistry, prenatal exposures, and/or early childhood experiences, are just plain difficult to parent - intense, needy, easily frustrated, inflexible, inattentive, hyperactive, impulsive, and so on. Or, if you prefer to look on the bright side of life ... spirited, sensitive, perceptive, persistent, and energetic.

If you're nodding your head, read on ... there are effective ways to parent, and perhaps even embrace these traits. The good news is, kids can change - but often we need to change our understanding and approach first. A good place to start would be with one or more of these resources. But bring it up with your doc as well, and consider a specialized parenting class, family counseling, "positive behavior support", or consultation with a developmental/behavioral specialist if you find yourself out of ideas or optimism.

You and your providers may also consider diagnoses such as ADHD, RAD, SPD, ODD, OCD, FASD, and other 3- and 4-letter-words. I'm not label-happy, and agree that it's easy to get lost in this "alphabet soup", but I am a believer in early, accurate diagnosis and treatment when neurologic and mental health disorders are involved. One way to start evaluating concerns about emotions, behavior, attention, and peer difficulties is with a screening tool like the Strengths & Difficulties Questionnaire.

Transforming the Difficult Child, by Howard Glasser and Jennifer Easley, is my favorite book for parenting, and yes, transforming, older children (over 5-6yo) who are difficult to parent, including kids with ADHD. It's also a lovely, positive parenting approach for "easier" kids. If you want a sample, check their website, and I've posted the first 2 chapters on our site as well. Glasser's belief is that normal parenting and teaching methods are designed for the "average child", and that the harder normal methods are applied to difficult children, the worse the situation can get, despite the best of intentions.

I really think this approach has arrived at a simple, but essential truth about parenting ANY child - we need to reverse our typical, inadvertent pattern of paying more attention to misbehavior than to good behavior. Instead of making a big deal over negativity ("why water the weeds?"), make a big fuss over the good stuff. Their Nurtured Heart approach has 3 basic aspects:

  • Super-energizing experiences of success
  • Refusing to energize or accidentally reward negativity
  • While still providing an ideal level of limit-setting and consequences

In Glasser's words, this approach helps therapeutically shift intense children to using their intensity in wonderful ways, and creates a world of first-hand experiences of prosocial behavior: "Here you are being successful ..." This is more than "catching kids being good", it's about having powerful ways to make any moment an opportunity to create success, by finding the good in what IS happening, but also in what ISN'T happening.

Do I love this approach? Yes indeed. You're very likely to find something useful, if not transformative, in this resource. As for his take on medications, I find it to be provocative, but not as much in line with our experience. The "energy" that kids with significant ADHD or FAS have is not always a gift to be cherished, and medications can be invaluable, as part of a comprehensive plan like the Nurtured Heart approach and school accommodations. But I am increasingly recommending a dedicated trial of this approach, plus the therapeutic parenting ideas in Gabor Mate's Scattered, before prescribing medications.

Another book that folks have liked is The Difficult Child: Expanded and Revised Edition by Stanley Turecki, which focuses on nine particularly difficult temperaments: high activity level, distractibility, high intensity, irregularity, negative persistence, low sensory threshold, initial withdrawal, poor adaptability, and negative mood.

A classic in the "insert-euphemism-here" child literature is Raising Your Spirited Child: A Guide for Parents Whose Child Is More Intense, Sensitive, Perceptive, Persistent, Energetic by Mary Sheedy Kurcinka, and her Raising Your Spirited Child Workbook.

"Inflexible, intolerant, and explosive" child? Try The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children by Ross Greene.

"Challenging" child? See The Challenging Child: Understanding, Raising, and Enjoying the Five "Difficult" Types of Children, by child development guru Stanley Greenspan, for positive parenting insights into "the sensitive child, the self-absorbed child, the defiant child, the inattentive child, and the active/aggressive child".

A website that draws on a number of these books, as well as her own experience parenting and running groups, is Elaine Gibson's The Challenge of Difficult Children. Lots of good, opinionated, from-the-trenches advice to be found here.

My favorite temperament resource is the "Preventive Ounce" website, for children up to 5 years old.  Learn where your child is on scales of Sensitivity, Movement, Reactivity, Frustration Tolerance, Adaptability, Regularity, and Soothability. Then check out a wealth of sound, temperament-specific parenting advice on issues that your child is likely to encounter in the next year. A good temperament site for school-aged children is INSIGHTS, with its online temperament profile.

Finally, a brief note on The Strong-Willed Child. James Dobson and his "embrace-your-inner-bully" theories are emphatically NOT RECOMMENDED, particularly for a child who has already experienced lack of attuned caregiving, violence, or other trauma.  The man beats his pet daschund with a belt on page 3 ... this is the guy you want helping you raise your kids? There are much better Christian parenting books out there that don't involve spanking your children into submission. The research on corporal punishment is overwhelmingly against it, and no amount of "folksy take-charge wisdom" or selective Bible interpretations should convince you to hit your kids.

Home Biofeedback

True confessions - both Dr Bledsoe and I have something at home called "Journey to Wild Divine". It's a home biofeedback system and "Myst-style" computer game that uses the same biofeedback technology (finger sensors measuring heart rate variability and skin conductance) that our local hospital's adolescent clinic uses to help with headaches, pain syndromes, self-regulation, and chronic stress.

We think it's an engaging and remarkably effective way to learn self-calming, better emotional control, and alertness, and have been recommending it to our older school-age patients with low frustration tolerance, poor self-regulation, ADHD, anxiety, and stress-related issues like headaches and chronic abdominal pain. The sensors measure signs of your nervous system's balance between sympathetic tone (energized, agitated, "fight-or-flight") and parasympathetic tone (calm, relaxed, "rest-and-digest"). Children who've experienced early stress and neglect tend to be chock-full of the former, with precious little of the latter. With practice, you and your kids can learn to calm yourselves much more quickly and effectively.

In the game, you move through an idyllic landscape, performing various tasks using your developing abilities to become calmer or more alert and energized. Levitating and gently lowering rocks, juggling balls, building stairways, and other nifty activities let you hone these skills until they become effortless. This game is begging for a Star Wars version, since it's really all about the Force, and Yoda would be quite at home with the game's collection of gurus ...

It's not cheap ($159), but that's about what one biofeedback clinic session would cost, and you can do it at home whenever you want. It's actually quite a good deal compared to other home biofeedback devices like HeartMath's emWavePC, handheld emWave (excellent portable device) and StressEraser, which I also like. You will need a fairly modern PC or MAC, since it uses a lot of processing and graphics power. You will also need a modicum of tolerance for SNAG's (Sensitive New Age Guys/Gals) and "what's my mantra?" mysticalisms.

I also recommend their followup game, "Wisdom Quest", which uses the same software but has 30 new biofeedback activities, which are easy to access through a new "Guided Activity Mode". You should also download a free update for their first game that enables a similar "Chapter Tour", so that you can revisit favorite activities without having to load saved games.

Another device that we have no experience with whatsoever but is appealing to my inner geek is S.M.A.R.T. Brain Games, a home neurofeedback device that uses actual brain wave sensors (instead of heart and sweat sensors) mounted in a bike helmet to help control Playstation (or Xbox) video games with your mental states. They use the ratio of beta to theta brain waves (a measure of focussed alertness and concentration) to control your speed and progress in off-the-shelf Playstation games, especially racing and jumping games.

The cost of this "brain training system"? $600 for the helmet, neurosensors, processor, and modified Playstation controller. Yowzah! But again, possibly cost-effective if you were planning on paying out-of-pocket for actual neurofeedback clinic sessions. For folks desiring neurofeedback treatment for a specific condition (like ADHD), you'd probably be best off starting, at least, with an experienced neurofeedback provider ... EEG Spectrum is a good place to start for general information and local providers.

The research on neurobiofeedback and ADHD is quite promising, if not yet definitive; see this "Play Attention!" article for a favorable take on this particular system, and The Role of Neurofeedback in the Treatment of ADHD for a review of the latest research. My opinion is that neurofeedback may well be a useful adjunct to other medical or behavioral treatments for ADHD. My hope is that it will be more broadly helpful for my patients with anxiety, dysregulation, PTSD, and perhaps even aspects of attachment difficulties. I'll keep you posted as I learn more ...