When Difficult Behaviors Arise Post Adoption

1. When Difficult Behaviors Arise Post Adoption Samantha L. Wilson, Ph. D.Associate Professor of Pediatrics, Medical College of WisconsinInternational Adoption Clinic, Child Development CenterChildren's Hospital of Wisconsin

2. Tentative Plan Currently, I plan to briefly discuss: • Impact of early adversity on brain/behavior • Grief/Loss within adoption • Promoting healing relationships Questions are welcome throughout….We’ll be flexible to accommodate the needs of this group!

3. Disclaimer • Content is not meant to imply that ALL children or families experience these questions/concerns nor that mental health services are always necessary if they do. • Some needs are developmental tasks, not necessarily adoption issues (though adoption can complicate typical developmental exploration). • You may leave here with more questions than answers….That is part of the process 

5. Unspoken Needs • Children enter foster/adoptive families with many needs. Some are evident early; others surface in the course of later development. • Common psychosocial concerns and unspoken needs: • Impact of trauma on brain development and behavior • Perception of loss and grief • Feelings of rejection, guilt, or shame • Fears of intimacy • Questions of identity

6. Early Adversity:Understand the impact of trauma on brain & behavior. • Many (though not all) children enter foster care/adoptive homes following some degree of early adversity: • Poor prenatal care/uterine substance exposure • Inconsistent caregiving • Lack of nurturing /neglect • Unresolved physical pain/hunger • Chaotic/Unpredictable care • Chronic environmental stress • Persisting fear • On-going physical threat

7. Stress in Young Children Trauma resilience

8. Traumatic (Toxic) Stress • Toxic stress = excessive or prolonged activation of the physiological stress response system in the absence of buffering relationships (AAP, 2012) • The stress response -- “freeze, flee, fight" -- is meant to deal with acute stress. It's not meant to be ‘activated’ all the time. • Ongoing activation of the stress response leads to ‘biological memories’ and can physically disrupt early (and later) brain development

9. Early Relationships • Early adversity is buffered through the relationship a child has with a primary caregiver • Relationships are the means through which children develop a stress regulation system and form the foundation of infant/early childhood mental health • Depending on the child’s pre-adoptive or foster care history, such buffering relationships may not have existed

10. Relationships Support the Stress Response System High Calm Arousal Adapted from B. Perry, MD, PhD. (2009)

11. Relationships Support the Stress Response System High Calm Arousal Adapted from B. Perry, MD, PhD. (2009)

12. It is not early adversity alone that is problematic, but rather the absence or insufficiency of early protective relationships.

13. Stress Model of Behavior Regulation Young children are inherently dependent on others for self-regulation (i.e., ability to tolerate stress) When infants and young children develop in neglectful or chronically stressful environments their bodies remain in a state of elevated distress Chronic elevation of this physiologically aroused state leads to 1. A physiological system that is sensitized to stress AND 2. A child who is ill-equipped to self-regulate physiological reactions to stress

14. Toxic stress and early adversity impact key brain structures in emotion regulation. Children who develop in the context of toxic stress have great difficulty regulating emotions and maintaining a state of calm

15. If early environments primed the brain/body for ongoing “threats,” later behavior can be extremely challenging. When we label behaviors as “good” or “bad,” we forget that children’s behavior is reflective of their earlier experiences.

16. Impact on Social Functioning • The more “activated” the stress response, the more difficult it is to interact positively • Social negotiation may overwhelm coping responses; often need increased support to facilitate social interactions • May be hypersensitive (and over-reactive) to perceived anger/rejection • When brain remains in “survival mode,” there is less room for considering the feelings of others

17. Parenting a Traumatized Child • If a brain wires among chaotic input, then entrance into a stable environment can be anxiety producing and the child may “work” to recreate familiar chaos • Positive interactions soothe the stress response system and allow the child to be receptive to new learning • Following developmental trauma, children are guided by their emotional brain…Parent reasoning is aimed at the thinking brain • Words will NOT have a great impact on children who are guided by emotional brain

18. Other Unspoken Needs Ok, I recognize that the stress response system gets dysregulated following early adversity…. What else should I think about?

19. Grief/Loss:Acknowledge sadness so its not overwhelming • “I wanted to put something in Dr. Sami’s book…I wanted to write ‘where’s my mom…why did she leave?’ ” 8-year-old, adopted at 4 years • “There were special ceremonies for adolescent girls…(sadly) I would have participated in them if I stayed in [birth country].” 14-year-old, adopted at 11 years • “I miss that lady…(i.e., birth mom)” 6-year-old, adopted at 3 years

21. Rejection:Reassure youth that they are valuable and worthy • “She would have aborted me if she could.” 11-year-old, adopted at 10 months • “My life was a mistake from the start.” 15-year-old, adopted at 4 years • “Foster care is where you go from home to home to see if somebody wants you.” 7-year-old, in foster care for 4 years

23. We don’t know ____________________but we do know that YOU WERE (and are) LOVABLE!

24. Intimacy:Support youth to have healthy ‘goodbyes’ and stay ‘connected’ • “It hurts to care about people because they aren’t around long” 14-year-old, adopted at 4 years • “I knew she would leave me – everybody does…(following death of family dog)” 10-year-old, adopted at 3 years • “Why should I care? People who say they love you eventually leave” 11-year-old, adopted at 11 months

25. Affiliation and Connection • Children may seek to reject others to thwart a future rejection of themselves, leaving them to be aloof or disinterested in others • Such behavior impedes emotional intimacy as a way to protect from future loss • Connections are sought outside of interpersonal relationships (e.g., pets, imaginary friends, substance use, excessive computer use) to replace the feelings of loneliness • Children need to learn ways to honor previous relationships and welcome new ones

26. So what can we do?? • Kids need support creating their life narrative to understand decisions that were out of their control and NOT because of them! • Lifebooks • Dear Baby Letter • How do we support healthy grief/loss expression? • Recognize grief as valid • Create rituals around it • Seek positive, symbolic connection with the “lost” • Know that elimination of grief is NOT the goal but rather resolution in accepting what is…. • Acknowledge that grief’s impact at various life stages may be different….that is OK!

27. On August 12, 2000 the world welcomed Sami, born at Chicago City Hospital! We are so glad you came into the to world…you have the potential to do great things!

28. Identity:Help me integrate the pieces of myself. Judy Kang - Pediatric Clinics of N. America (2005) pg. 1507–1515

29. Identity and Adolescence • Like all teens, adopted adolescents are in the process of trying to define themselves and find their place in the world. This process may be more complicated with so many unknowns… • Integrating knowledge (or lack) of their birth parents/birth culture and adoptive status is challenging & can create emotional distress. Do I look like anybody? I wonder where I ‘fit’ in?”

30. Racial Identity • As with adoption identity, racial identity may increase in importance during adolescence with increased awareness of racism and “different-ness” • As adolescents separate from the family, they are increasingly seen as a person of color and will be treated as such.

31. Stereotypes, Discrimination, & Racism …Oh My! African American, Asian, and Latino youth face both subtle and blatant racism/stereotypes from classmates, teachers, and administrators Frequent microaggressions send messages to our kids: “I thought all Black people liked rap.” “I don’t even think of you as ______________ because you act _______________(white)” “Are you sure you’re Asian…you suck at math!”

32. Narrative Burden People of color are too often expected to be "spokespeople" for their race - Peggy McIntosh (sociologist) If one lives in a community that is not diverse, this might happen to youth on a daily basis Adolescents who were adopted may experience additional “burden” to explain themselves, their families, and their life stories

33. Children Need Adults To: Be patient and understand the impact of trauma on their brain and behavior. Reassure them that they are valuable and worthy. Acknowledge (and share) sadness so that it doesn’t overwhelm them. Remind them that they can be connected to others and have healthy ‘goodbyes.’ Support them to integrate the pieces of themselves and internalize a sense of belonging.

34. Family relationships provide the safe haven for youth to explore and understand myriad feelings and complexities in their lives.

35. Ongoing Conversations • Reflect on your own internal fears/beliefs about grief, birth parents, adoption, race, etc. • Mention topic early and look for natural openings • Conversation is a PROCESS not an event • Be sure to LISTEN, not just lecture • Just because your child doesn’t bring up ________ doesn’t mean they don’t think about it

36. Welcome the Process Most conversations occur “in between” times Listen, validate, and accept Allow the youth to feel _____, acknowledge your feelings: “You wish you knew more about your birth mom” “I am sad that I can’t protect you from stereotypes” Provide openings: “I hear a lot of stereotypes about psychologists….what stereotypes have you heard?” “What do your friends ask about adoption?”

37. I Encourage You To: Nurture adults relationships – Find your community Play adoption with young children & revisit adoption stories with teens Be curious about your child’s experience and emotions Explore race and privilege (white privilege, non-adopted privilege, etc.) Acknowledge birth parents - give permission for child to wonder Connect daily and laugh as a family! Seek support if overwhelmed

38. Internet Resources • Child Trauma Academy (Bruce Perry): http://teacher.scholastic.com/professional/bruceperry/index.htm • Institute of Child Development (Karyn Purvis): http://www.child.tcu.edu/ or http://empoweredtoconnect.org/ • Beyond Consequences (Heather Forbes): http://www.beyondconsequences.com/ • Dyadic Developmental Psychotherapy (Daniel Hughes): http://www.dyadicdevelopmentalpsychotherapy.org/ • Perspectives on Adoptive Family Building: http://www.adoptattachtherapy.com/articles.html • Teen Adoption Communityhttp://www.adoptionbeat.org/ • Transracial Adoption Supporthttp://www.pactadopt.org

39. Internet Resources • Removed (12-minute film portraying transitions through foster care)http://vimeo.com/73172036 • Adoption Learning Partners (various webinars)http://www.adoptionlearningpartners.org/ • Creating a Familyhttp://www.creatingafamily.org/ • Impact of Adoptionhttps://www.childwelfare.gov/pubs/f_adimpact.pdf • Parenting a Child who was Sexually Abusedhttps://www.childwelfare.gov/pubs/f_abused/f_abused.pdf • Searching for Birth Familieshttps://www.childwelfare.gov/pubs/f_search.pdf • Maintaining Sibling Relationshipshttps://www.childwelfare.gov/pubs/siblingissues/siblingissues.pdf

40. Internet Resources • Inside the Teenage Brain: http://www.pbs.org/wgbh/pages/frontline/shows/teenbrain/ • Adoptive Families (various free webinars) http://www.adoptivefamilies.com/webinars.php • Beyond Culture Camp (Donaldson Institute)http://adoptioninstitute.org/old/publications/2009_11_BeyondCultureCamp.pdf • Pact – An Adoption Alliance for Children of Color: www.pactadopt.org • C.A.S.E. Teens Support: http://www.adoptionsupport.org/res/teens.html • Birth Parent Lettershttp://www.lettersforthem.com/

41. Regional Resources • Wisconsin Post-Adoption Resource Centers: http://dcf.wisconsin.gov/children/adoption/programs_servic es/post_adoption/resource_centers.htm • Children’s Family Support Services (many locations):http://www.chw.org/childrens-and-the-community/family- support-services/counseling/ • Healing Hearts (Madison): http://www.healingheartscares.com/ • Children’s Research Triangle (Chicago): http://www.childrensresearchtriangle.org/ • International Adoption Clinics: www.chw.org/internationaladoption (Milwaukee) http://adoption.umn.edu/ (Minneapolis) • Saint A’s (Milwaukee, school-based services): http://www.sainta.org/services/

45. Contact Samantha L. Wilson, Ph.D. 262-432-6600 International Adoption Clinic, Children’s Hospital of Wisconsin www.chw.org/internationaladoption