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Home > Substitute Care Providers: Helping Abused and Neglected Children > Substitute Care Providers: Helping Abused and Neglected Children: Meeting the Needs of Abused and Neglected Children
Substitute Care Providers: Helping Abused and Neglected Children
User Manual Series (1994)
Meeting the Needs of Abused and Neglected ChildrenThis manual cannot teach the full range of skills and techniques that foster and adoptive parents must use to help them meet the needs of a maltreated child living in their homes. However, this section will attempt to present several concepts to guide those who work with the child in substitute care and share some specific techniques that can be useful. It was suggested earlier that abused and neglected children in substitute care demonstrate the following:
The assessment process is intended to sort out the various levels of need and to help focus therapeutic intervention where it is most needed and will be most effective for each child. The Assessment ProcessAssessment is the process of gathering and evaluating information and comparing that information to some sort of normative data. In assessing a child who is already in substitute care or who is entering care, professionals must be mindful of two norms. They must be knowledgeable about what constitutes normal behavior based on a sample of all children at various chronological ages, and they may recognize what is considered normal behavior for children of various ages who are also in substitute care. The assessment of a child in substitute care is geared toward understanding how the child functions cognitively, socially, and emotionally. It is also important to understand the impact that placement has had, or will have. Whenever possible, information should be gathered directly from the child, the child's caretakers (both past and current), other professionals who have known the child, and from recorded information about the child. Information should be gathered and organized according to the following nine categories:
The level of a child's development is usually assessed in five areas. First is physical development. Child welfare staff must determine whether the child has developed within the normal range of physical growth and is in good health, or if there are delays in physical development or special medical concerns. Second is social development. The caseworker must assess how the child interacts with the environment, particularly with other people. Third concerns the child's emotional responses. Are they appropriate for a child of that age? Fourth is cognition. The caseworker must understand that the chronological age and physical development of the child is especially important because cognitive capacity is more difficult to measure for a preschool-aged child or for a child whose physical development may be slower than the norm. Fifth is the degree of congruence among the other four areas of development. Although all children develop somewhat unevenly, most children develop in the above areas at about the same rate. A child coming into care usually shows greater discrepancies among the various developmental areas or even significant lags in one or more of these areas. The capacity to make meaningful attachments is important throughout life. It is especially important to assess this capacity for a child in care because attachment capacity is something that can influence the success of care or that can be therapeutically strengthened as a result of care. Attachment is a learned skill. If a child has his/her basic needs met from infancy to age 3, the child will also learn to trust and become affectually involved--first with the primary caretaker and then with others. Many children coming into substitute care have not experienced a stable, nurturing, consistent relationship with an adult during their first 3 years. As a result, these children come into care with various forms of attachment disorders. During assessment, the caseworker must discern the child's capacity to make attachments or identify the nature of any attachment disorder. Attachment disorders fall into three categories. Those children who have been severely deprived of nurture and affection during their first years may be children who are nonattached. Simply put, because they have never experienced a meaningful attachment; further, these children do not know how to form such a relationship. The second type of attachment disorder, more common to children in foster care or adoption, is that of the inadequate attachment. These children have had their basic needs met at various points during their early years, but their primary attachment was interrupted by the necessity of having multiple or intermittent caretakers. A child demonstrating inadequate attachment might have had several placements between infancy and age 3, or the child may have had a primary caretaker who was a substance abuser who took good care of the child when not under the influence. An inadequately attached child responds well to substitute care that is consistent, allows for regressive behavior, and makes no immediate demands for affectual closeness with other family members. In time, the child can learn how to become affectually involved, though not always to the degree that might have occurred if he/she had an opportunity for consistent early care. A third type of attachment disorder is demonstrated by a traumatized child. In this situation, a child had been experiencing sound caretaking and was developing a positive view of the world and of relationships when some traumatic event interfered. The young child might have been sexually abused by a trusted adult, or the child might have had to deal with the sudden loss of a primary caretaker because of death or placement in care. Although such attachment disorders are serious, they are the most easily treated. In the case of anticipated death or placement, the trauma can be mitigated by explanation, preparation, sensitivity, and postplacement contact. If the caretaker's loss is unexpected, or the trauma is due to sexual abuse, treatment based on the posttraumatic syndrome model can be effective. In assessing the impact on a child who suffers from an attachment disorder caused by trauma, it is important to consider the child's age when the trauma occurred, the nature of the trauma, and the capacity and the stability of the substitute home to which the child is moved. A child who learns attachment when older never learns as well as if it was learned at a more age-appropriate stage of development; however, subsequent interventions can help mitigate these attachment disorders. Trust is a key element in the child's recovery. Trust can be learned, and it is the beginning of the healing process. A preschool-aged child can learn attachment if he/she is placed in an environment in which the child has an opportunity to form a significant primary attachment by regressing to an infantile level and having his/her needs met by a consistent caretaker over a prolonged period of time. Between the ages of 5 and 11, a child can learn attachment if adult caretakers can create opportunities for the child to have earlier caretaking needs met symbolically. Caretakers must design ways to interact with the child just as a mother would interact with an infant or toddler while discouraging infantile behavior and without inappropriately stimulating the child. Examples include an adoptive mother who structured regular, intimate parental touching by washing and combing her daughter's hair, or a foster mother who put sunscreen on her 10-year-old son's back as a safeguard against exposure to the sun when he was swimming in an outdoors pool. Adolescents can be helped to learn attachment by demonstrating appropriate behavioral skills, such as how to hold eye contact or how to hug. Young adults may learn attachment if they become involved in a relationship with someone who is a competent caretaker, or they may learn attachment techniques in the process of helping their own children learn how to attach. The assessment of losses in the lives of children relates directly to their capacity to make attachments and is a critical factor in planning and implementing successful substitute care. The loss of family is a core issue in the placement of any child. The child's earlier experiences determine how he/she reacts to that loss and what interventions can be most helpful. In addition, any other losses the child might have sustained, the circumstances and timing of those losses, how the child managed those losses, and the extent to which those losses have been resolved are factors that should be assessed. Losses are resolved successfully by experiencing a grieving process; that process takes time and support. Any new loss during the grieving period means the process must start anew, and a series of successive losses may stall the process completely. Because they want to ease a child's grief, adults respond by trying to block the child's grief or by speeding up the process. Adults involved with a child in substitute care need to understand the child's past experiences with loss, and they need to be comfortable with helping the child grieve. Techniques to assist foster parents deal with a grieving child will be described in a later section of this manual. "Identity" is a sense of one's self and of one's boundaries and values. Identity includes knowing who we are and how we fit into our surroundings. Because we spend all of our lives becoming who we are, our identities are never fully formed. There are, however, six critical components to one's identity that evolve throughout the normal development of children. Those components are as follows:
The identity of a child in foster care or adoption is often shaped by the circumstances that initially brought him/her into care and by the experience of being in foster care. The child usually faces difficulties with every component of identity mentioned above:
Children are remarkably resilient. Whatever their early experiences, most have developed ways to manage their lives. Children are not always aware of what mechanisms they use or just how they learned them. Some of these ways are unconscious defense mechanisms, which will probably never be identified. Other responses, however, are conscious techniques that a child has learned from his/her own experience or from observation. For some children, these behaviors (or coping mechanisms) have become habitual, although most children are not usually aware when they utilize them. Other children, however, very consciously and deliberately use these techniques. It is useful for substitute parents to have some sense of the types of coping mechanisms a child is likely to employ so they can better understand the child and respond appropriately when the child exhibits such coping mechanisms. It is also important for child welfare staff to identify these behaviors and evaluate whether they are likely to work to the child's long-term advantage or whether efforts should be made to alter or replace the behaviors. A child coming into substitute care needs to determine the "dimensions" of the setting. The child needs to learn such things as family boundaries and roles, the important rules of the household, the expectations that are being placed on him/her, and the tolerance for and the consequences of misbehavior. Children determine boundaries in several different ways. Some children immediately engage in testing behavior; that is, they quickly push to the limits to learn what those limits are. Other children need a period of acclimation before they do their testing; and still others learn what they need to know from observation alone and never engage in direct testing behavior. Often, a child who has been moved frequently learns to cope through manipulation. The child may become a practiced liar, able to persuade foster parents, caseworkers, teachers, and strangers the truth of false statements. Another child may learn how to "play off" the other members in the family to his/her advantage. Yet another child may carefully observe the kinds of behavior and expressions of feelings that seem to work for others and mimic these behaviors in his/her relationships. Such a child may lack the capacity to feel as deeply as another person or be unable to express that feeling in a genuine way, but he/she will pretend to have the feeling if he/she thinks that it is expected or that it will be to his/her advantage. A third kind of coping behavior that is useful to assess is the repetition of patterns of behavior that are based on the child's past experiences. Sometimes the behavior appears bizarre or self-defeating unless professionals understand its roots and the reasons for its repetition. For instance, if a child has experienced trauma in the birth family or in a previous placement, the child may try to recreate the experience in an attempt to master residual feelings from the earlier experience. If the child has experienced rejection in the past because of his/her behavior, he/she may repeat the same behavior to see it if will elicit a similar response, or the child may engage in similar behavior but try to stop before suffering such dire consequences. This is an attempt to master the behavior or manage the trauma more than to test the new family. The child is trying to gain greater control over the circumstances of his/her life. Situational Needs and Responses One important, but often overlooked, area of assessment is a child's situational needs and responses. Professionals often view a child's behavior as distinct from the environment in which the child lives. What appear to be character traits can in fact be spontaneous responses. What may appear to be negative character traits can be a healthy reaction to an unhealthy situation. A change of environment can solve many problems. It is, therefore, extremely important for the caseworker to assess what needs and behavior are situational by becoming familiar with the child's total environment. Understanding of Status and Expectations of Future Another factor in assessing a child in substitute care, or a child for whom such care is being considered, is to observe the child's understanding of his/her situation and what substitute care entails. How a child perceives care and what that child views as its best and worst resolutions are significant factors in case planning. A child's understanding will be limited by age, by past experience, and by the degree of the child's involvement in the planning. That understanding will also be shaped by what the child perceives as actually happening. This can be best assessed through interpersonal interaction with the child. An older child can usually articulate what placement and care mean to him/her; however, for a child who lacks cognitive or verbal skills, drawing and play may provide relevant clues. Relationship to and Meaning of Birth Family Because a child in foster care and adoption always also belongs in part to the birth family, it is important to assess what the current relationship is between a child and the birth family and the significance that family has to the child. The meaning and importance of the birth family will depend on the age and developmental level of the child; the current membership, integrity, and level of functioning of the family; the circumstances and timing that led to the child's placement; the history of the child's experiences with the birth family; the child's understanding of care; and the goals of the placement. Visits between a child in care and his/her birth parents are often sources of concern and tension. Although they provide an opportunity for a child to understand and resolve his/her foster care or adoptive status, such visits also provide opportunities for acting out feelings or for manipulation. To make visits a positive and valuable experience, the caseworker should attempt to ensure that all parties clearly understand the goals of care and the meaning of foster care or adoption. If foster parents are viewed as a substitute extended family and the goal is the reunification of the birth family, most foster parents can comfortably support the birth parents' attempts to learn to become better parents. Foster parents do this by modeling positive parenting skills, encouraging the birth parents to perform parenting tasks when they visit (e.g., shopping with the child or helping with homework), and by teaching the birth parents parenting skills (such as grandparents might in a well-functioning extended family). If foster parents are viewed as a substitute extended family and the goal is termination of the parental rights and adoption of the child, the role of the foster parents during visits depends on whether they intend to adopt the child. Most adopted special needs children are adopted by their foster parents. Often, the birth parents voluntarily release the child because they have come to know and trust the foster parents through visits, and the birth parents want the foster parents to adopt the child. If some other family is to adopt the child, the foster parents can facilitate the adoption placement by using visits with the birth family to allow the birth parents and the child to come to terms with the fact that they will not be reunited. The foster parents' commitment to the adoption plan and the positive relationship they have established with the birth parents can serve as a bridge to the new family for the child. Such a process helps the child feel free to form new attachments without guilt and to adapt to the new situation. One of the developmental tasks of an adopted child is to accept and resolve his/her dual heritage. The nature of the relationship between the adoptive family and the birth family can make a significant contribution to the success of the adoption. When the adoptive parents can figuratively accept the child's birth family into their home, much of the trauma of the adoption is alleviated, and a firmer basis for the child's identity is laid. Recently, there has been a trend toward a more literal acceptance of each other by the birth family and the adoptive family. When there is an opportunity for some sort of relationship between the two families, the adoption is called an "open adoption." Because most older children enter adoption with a history of living with their birth families or with memories of the family, and because many of these children are in contact with the birth family when they are adopted, there is usually no choice about whether such adoptions will be open. Increasingly, however, infant adoptions are also becoming open. Birth and adoptive families may engage in a mutual selection process, may meet each other at the time of placement, and may agree to some contact following the placement. Although it is too early to assess the long-range effects of openness, such adoptions provide the adopted person with easier access to the birth family and a greater opportunity to get information and work out concerns about the reason for adoption. Open arrangements can be complicated and must be implemented very carefully, with all parties aware of the consequences. Finally, it is important to assess the personal lifestyle of an older child in order to understand that child's needs and how best to ensure that placement in a substitute family will be successful. Lifestyle includes all of the idiosyncratic variables that make children so different from each other. Lifestyle is not necessarily related to a child's developmental level, his/her experiences with placement or loss, or to any of the other factors already listed. Often, the unique characteristics of a child cannot be measured objectively. It may be some unusual trait or characteristic, or it may just be the way that a child approaches life or the responses he/she engenders in others. For instance, some children have such infectious smiles that whenever they smile they alter their surroundings. Further, some children possess some inner determination that enables them to achieve far beyond their apparent capacity. Although they are difficult to catalog or analyze, lifestyle behaviors are extremely important. Lifestyles frequently determine the compatibility of strangers. Relationships work best when people cherish each other's unique qualities and approach to life. Assessment is an ongoing process that can serve at least four purposes in helping abused and neglected children in family foster care or adoption. These purposes are as follows:
Providing a Safe EnvironmentThe first and most essential task for the foster or adoptive parent is to provide a safe environment for the child to whom they are offering care. The next task is to help the child accept that the environment is, indeed, safe. For a child coming into care as a newborn, this security is provided through the consistent meeting of the infant's early developmental needs. The child may have been exposed to an unsafe prenatal environment. Furthermore, most children coming into care who are not infants have been exposed to an unsafe environment. Subsequently, the placement itself exposes these children to fear and uncertainty. One aspect of security is the sense of commitment by the caretakers. This is an area in which many older children know their parents have faltered. Most of these children may already have experienced several other substitute homes. How can a child feel secure if he/she does not know how long it will be before he/she has to move again? By definition, foster care is time-limited. Anxiety about what comes next is inherent, and all therapeutic interventions need to take this factor into account. Foster parents need to be careful not to deny the issue or the anxiety by reassuring the child that he/she is welcome to stay as part of the foster family. This gives the child a message with a double meaning, which can only confuse the child and make him/her feel less secure. The sense of security will develop directly from the honesty of the caretakers and the willingness of those caretakers to help the child face, not deny, his/her anxiety. Assessing a Substitute Environment Child welfare professionals cannot guarantee that the environment into which a child has been placed is safe, but they can carefully evaluate families and use their knowledge and skills to try to assure that the child will be safe. Doing this poses something of a dilemma for those responsible for licensing, training, and monitoring substitute families. There are a large number of children waiting for adoptive families. Many of these children have been waiting a long time because meeting their special needs would prove too challenging for most conventional families. Generally, conventional families have little interest in parenting children not born to them, especially those children who most need permanent families. Furthermore, some of these families function well within the boundaries of their own experience, have led relatively problem-free lives, and have not had reason to develop the coping skills or use the kind of resources that are necessary to parent special needs children. Adults who have had their fair share of problems are often the very persons who do not easily fit the model society has of the kind of parents who will provide a safe environment for a child. Licensing requirements and agency guidelines for making assessments that provide security for children are not always congruent. Licensing tends to rule out categories of adults on the basis of statistical probability (e.g., persons convicted of certain felonies or indicted for abuse, etc.). Some agency guidelines try to accommodate the possibility that individuals grow and change, and that, in fact, some negative experiences may equip these adults to cope better with the difficulties that a child in substitute care may face. Careful assessment is necessary to determine how an individual has grown from past experiences. There is always going to be some risk involved in placing a child in substitute care. Agencies that place special needs children try to keep arbitrary eligibility requirements to a minimum. These agencies use the orientation, assessment, and preparation process; caseworker assessment skills; and preplacement and inservice training to establish a cadre of homes that they feel are safe for a child. The agencies actively monitor the child's care and provide support services for the foster family. Although there are no foolproof methods of predicting a family's response to a child or the child's safety in a home, there are predictive indicators. When foster parents have a child of their own, the child's general well-being suggests the quality of care the home provides. One of the criteria for successful substitute parents is their capacity to make and maintain a commitment to a child. During the assessment process, the child welfare caseworker needs to explore the nature of past commitments that the family has made and kept. A history of family stability in areas such as employment, housing, and social networks tends to predict stability in the future. Routine reference letters are of little value; however, personal contact with references, even by telephone, can give a picture of the family's personal history and characteristics. Of particular concern is the foster parents' extended family. Positive extended family relationships and activities suggest that a support system is already in place. Further, parents who show a sense of "connectedness" with their extended families transmit to the child the subtle, but very real message, of belonging. For a child in care, this sense of belonging is often one of the most significant ingredients lacking in the child's life experience. Other issues that relate specifically to whether a child will be safe in his/her new family have been identified in the literature. For example, Bourguignon and Watson 29 suggest that there are eight "red flags" potential families present that signal possible danger. The red flags warn the caseworker to proceed with caution and investigate further. They are as follows:
Although no one red flag is in and of itself a reason not to proceed with placement of a child, any one may be, and the presence of two of more would certainly raise serious questions about the suitability of a placement plan. Caseworkers moving a child into care, or from one place to another, and the family that is receiving a new child into care need to work together to help the child feel safe in the new home. Agencies need to help the child understand that he/she lives in a world with many different parts, each of which is connected to the child's life. To ask a child to enter a new world, while completely closing a past one, is confusing--even devastating--and very rarely necessary. The agency must help the child form bridges between the present and the past. Before the child visits a new home, it is helpful if the caseworker has assured an exchange of information between the child and the new family. This information may take the form of pictures, cards or letters; a videotape; telephone calls; or anything else that will help the placement seem less threatening. The first visit to the new home is critical, whether it occurs as a part of a preplacement process or occurs on the day the child moves in. Whenever possible, preplacement visits should be scheduled because they provide a chance for the child to get acquainted with his/her new surroundings and with the strangers who will soon be family. At the same time, these visits provide the child with a sense of security by returning to his/her current residence to sleep once more in familiar surroundings. Moving into a new family is frightening. The child welfare caseworker and the family members must try to allay the child's fears. The greatest initial fear for a child coming into a new family is that all ties to the past will be severed permanently. The child may worry that the birth family will not know where he/she is, that he/she will never again see members of past foster families, or that the new family will not allow contact with old friends. Unfortunately, past placement practices all too often confirmed these worst fears. Now, however, sound practice works to reduce or eliminate those fears. The first thing a child should be shown in a new home is the bathroom; the second is the location of the telephone. The child should be encouraged to make calls to those persons who are significant to him/her. Any family rules about the use of the telephone should be stated clearly. The first visit should focus on environment rather than relationships. Relationships may be one of the things the child finds most fearful, and there will be time in the future to develop relationships. Initially, a child can be helped to feel more secure by getting acclimated to his/her new surroundings. A tour of the living quarters ought to include opening every closet, a quick look under the beds, a tour of the attic, and a visit to the basement. Equally important, the new child should meet all of the people who live in the home. After the tour, the child should be told the three or four most important family rules. Such "rule-sharing" reassures the child. There are rules here (not chaos), and the family will help the child understand what those rules are. The few rules shared at that first visit should relate, if possible, to how the family ensures its members' own safety. Some examples are rules about leaving the house, respecting each other's privacy, and being in someone else's bedroom. The rules should be real, important, and simple. Coping with Regressive BehaviorProfessionals should assume that any child coming into foster care or adoption will manifest some reaction to the new home and that the most obvious sign will be some regression. The older the child and the more trauma that is associated with the placement, the greater the developmental regression. In addition, many of the children coming into care are already developmentally delayed. Therefore, many substitute parents are dealing with a child who may already manifest developmental delays and who is probably experiencing some developmental regression as a result of the placement. It can be no surprise, then, that a child placed in foster or adoptive care is likely to exhibit immature behavior. One of the first things that substitute parents must learn is how to accept age-inappropriate behavior. They must learn how to respond to the child as he/she presents him/herself; yet, the substitute parents must provide the child with what he/she requires to begin to recover from any developmental delays. If a child is developmentally disabled or severely developmentally delayed, parents must also adjust their expectations to realistic levels. The therapeutic process for helping a child with developmental problems begins with accepting the child in his/her current developmental stage. It also includes allowing or encouraging further regression to fill in earlier developmental gaps and then meeting the child's developmental needs in symbolic ways that do not inappropriately stimulate the child or encourage more infantile behavior. There is a natural tendency for all of us to expect people to respond according to their chronological age or their physical size. "Act your age," is a common admonition that adults use with children. Telling a child that he/she is "too big" to be acting in a certain way is also common. Often, a child in foster or adoptive care does not behave in a way commensurate with the child's chronological age. This is usually difficult for the adults helping the child, whereas such behavior may actually be beneficial to the child. The child needs an environment in which he/she can regress, both to feel safe and cared for and to recapture some of the experiences the child may have missed earlier in life. The first task of the substitute parent is to accept the behavior that the child presents. That does not mean to accept behavior that is harmful to the child or to others or that is otherwise violent or destructive. The substitute parent should keep in mind that the first need of a child is to feel safe. What is required is that substitute parents carefully and clearly establish the limits of acceptable behavior (as generous an interpretation as possible), while reassuring the child that any behavior that jeopardizes the security of the child or of others is not acceptable. Such behavior must be controlled by the parents until the child has the ability to control it. But even in controlling the child's behavior, the parents must accept it as part of the child. They must convey to the child that limiting the behavior is not denigrating the child. The limits are necessary for the child's or others' protection until such time when that the behavior is altered into a less dangerous form or is no longer necessary. For example, a 6-year-old child who is angry with his foster mother may grab a butcher knife and threaten to stab her. The mother must disarm the child and protect herself and the child from serious harm. She must try to convey the message that such violent behavior is not acceptable yet recognize in her response the legitimacy of the child's anger and the need to express it. Necessary external control of a child's behavior should be followed as soon as possible by an opportunity for the child to act at a regressed age level in some way that is not harmful. This might be achieved by playing some game that is "younger than the child" or engaging in some childish activity that is developmentally related to the age at which the child was acting. When a 12-year-old expresses rage through behavior that is appropriate for a 3-year-old, the child should not be encouraged to express rage in some other way. Rather, it is important that the adult try to meet the child's needs at the 3-year-old level of development. The focus should be on the child's developmental age, not on the child's rage. If the behavior would be "normal" for a 3-year-old, what are the developmental needs of a 3-year-old? Can they be met symbolically? Temporary regression is often necessary before the child can move on to more age-appropriate behavior. Helping Children with Feelings of LossBecause the most important concern of a child in care is loss, this topic has occupied a significant amount of attention from therapists and authors.30 Numerous techniques that are easy to learn, but not always easy to implement, have been developed to help a child deal with loss. Loss is a universal experience. As people mature, they learn ways of dealing with feelings about being temporarily separated from those who are important to them as well as feelings about permanently losing loved ones. Any loss is always painful because of its immediate impact and because it awakens feelings and memories of earlier losses. Because loss is a universal experience, parents and therapists already have the tools to help a child with his/her losses. Those adults can draw from their own experiences to understand and empathize with the child. What is necessary is a framework within which to understand loss and practice therapeutic intervention. When a person suffers a loss, he/she grieves. The feelings of grief are strong, painful, and difficult to sort out. Although they never come one at a time or in perfect order, there are several stages common to the grieving process; these stages are identified by the feeling that is strongest at that time. Several theoretical models for examining the grieving process have been constructed. The model presented in this manual identifies the following five stages:
The only way out of the pain of a loss is to experience the grieving process. It is almost impossible to get through the process alone. To help a child through this process, adults must first reach within themselves to find and touch their feelings about a loss they have experienced. Then, the adults can try to identify what they think the child may be feeling, giving permission for the child to have that feeling, whatever it is. After accepting and sharing the child's feeling, the adult can very gently try to encourage the child to move on to the next level in the grieving process. The child may move on, refuse to budge, or retreat to an earlier stage. Whatever the child does is all right. If the move is forward, the adult again accepts and shares the feeling. If there is no movement or the child retreats, that too is accepted. There will be other opportunities. If the adults acknowledge that it is acceptable behavior, a child will allow him/herself to grieve. The problem is that no adult likes to see a child in pain. The adults tend to join the child at the denial stage, argue the child out of the guilt stage, or fight back at the child in the anger stage. Thus, the adults do not have to endure the child's pain. They tell the child "Don't worry about the past," "Everything will be all right now," "It wasn't your fault you were moved," or "Don't talk to us that way because we're not responsible for what happened to you in the past." Again, the technique for helping is easy to learn but less easy to implement. The adults must allow the child to feel pain, quietly accept the child's pain, and through this sharing and support, make it somewhat easier for the child. Helping Children with Issues of IdentityFoster and adoptive parents have an opportunity and a responsibility to help any child in their care with issues of identity. Foster and adoptive parents can do this by respecting the child as an individual and by clearly understanding their role in the child's life. The definitions of foster care and adoption that have been presented in this manual stress that a child in care already has another family--either one to which he/she will return or one which becomes part of a new kinship network when the child is adopted. The family of origin is always a significant part of the child's identity, and the child has a right to as much information about that family as is known. The foster or adoptive parents must learn all they can and share this information with the child. Even unpleasant background information must be shared. It is part of the child's heritage and identity. Foster or adoptive parents should answer the child's questions about his/her family simply and directly. The substitute parents should then attempt to respond to the feelings that prompted the question or that may have been rekindled by the response. Although it may sometimes be permissible to delay sharing some information with a child because it seems too destructive at that time, it is never permissible or helpful to withhold background information or to lie to a child about his/her history. In helping a foster or adopted child develop his/her identity, it is important for foster or adopted parents to understand that they cannot change the foundations that the child brings to placement. Rather, the substitute parents must take what the child already has and add to it. Thus, the foster or adoptive parents must encourage the child to bring into his/her new home as much of his/her former self as possible. It means that the foster or adopted parents must cherish what the child brings. This is not always easy. Sometimes what the child brings is not "nice." The child should be allowed to bring his/her cardboard boxes or plastic garbage bags with his/her often meager belongings. Further, the child should be allowed to bring his/her dirty clothes, bad manners and disturbed behavior, pictures and memories, and his/her name. The child will discard the boxes and garbage bags when he/she is certain these belongings are no longer needed. There will be time enough to sort through, wash, and replace the clothes when the child feels more secure. The child's manners will improve, and his/her behavior will change. The child's photographs and memories are intrinsically valuable. Photographs and snapshots should be placed in a Life Book, and that book should be looked at and discussed to let the child know that his/her past is accepted as a significant part of the child's identity and to provide opportunities for the child to sort out and share his/her previous experiences. All children, except for newborns or those who have been abandoned, bring their names with them when they come into foster care or adoption. Foster and adoptive parents must always exercise extreme caution about suggesting or accepting name changes. A name (whether a family name, a given name, or a nickname) is a fundamental part of a child's identity. Sometimes, foster or adopted parents assume that encouraging or allowing the child to change his/her name will hasten the child's sense of belonging to the new family. Rather, this behavior may be interpreted by the child as a message that what he/she brings from the past is not acceptable. For foster parents, a good rule of thumb is to ask the child what he/she was called in the previous home and what other names the child may have used. The foster parents should not offer the child a choice about the name to be used in their home until they have explored the meaning the name has to the child. The child may "choose" a name that has been assigned in a former home but that has negative implications to the child. The foster parent should note whether a child gives only his/her first name, both the first and last names, or just the last name. In talking with a child about his/her first name, one of the goals is to discern what the birth parents named the child and what name the parents actually used when addressing the child. In some situations, a name is one of the few things that the birth parents were able to give their child. If the child gives a first name only, the foster parent can ask who actually named the child and whether the child is accustomed to being called by that name. If the name the child is accustomed to is the name that the birth parents used, the foster parents should use that name. If the child protests, the foster parents have an opportunity to discuss the child's feelings about the name and about his/her birth family. If the name is different, the foster parents can use this opportunity to discuss the child's birth family and the meaning of the name to the child. When asked about what they were called previously, some children give both the first and last names, or just the last name. In such cases, initial attention should be directed to the last name. By focusing on the last name, foster parents can clarify their role and help the child establish his/her sense of identity. If the child gives the birth family name, the foster parents can reinforce membership in that family and the child's right to that name. If the child gives a last name other than the birth family's name, the foster parents can clarify what the real birth name is and explore why the child chooses to use another name. Frequently, foster children use the last name of the foster family with whom they reside. Because children are usually registered in school under the name on their birth certificate, the use of the foster family name may complicate the child's situation at school. It is acceptable for the child to use the foster family name if the child understands that the use of that name is temporary and that it is used only as a convenience during the period of time when the child is residing with that family. Discussion around this issue provides an excellent opportunity for foster parents to help the child understand the meaning of the foster care placement. For adoptive parents, changing names provides a similar opportunity to help the child understand what adoption actually means. Except for some newborns, children arrive in adoption with a name. As with foster children, that name should be respected and accepted; however, in adoption a change of name is a symbol of a change of status. Changing the last name is a part of the legal adoption procedure. Changing the first name is also symbolically important and should not be done casually. Adoptive parents face a dilemma with a child who has been given a name by his/her birth parents. If they change that name, the child may sense rejection of a part of him/herself that was given by the birth parents. If substitute parents do not change the name, the child may feel not fully claimed as their child. One solution is to try to do both--change the child's name, but retain the old name as part of the new name. This approach is easily accomplished by giving the child a new first name and using the old first name as a middle name or by changing the original last name to a middle name. When an older child who has long used his/her first name is adopted, it may be preferable to keep the original first name and add a new middle name at the adoption to reflect the change of family status. Because there is no limit on the number of middle names, some families add several family names as middle names in order to reinforce the new family's claim to the child. The focus on belongings, memories, and names is often difficult for foster parents and adoptive parents for three reasons:
A child's past is important, of course, and cannot be changed. Foster and adoptive parents must help the child in their care accept whatever past he/she has had and build a better future from those experiences. At the center of one's identity is the sense of one's self-worth. When a child speaks negatively about him/herself (whether about his/her appearance, name, foster care or adoptive status, or anything else), the best initial response of parents is to remain silent. It is tempting to rush forward with reassurance, but a more effective first step is to allow the child to "own" his/her feelings by empathizing with the feelings rather than by attempting to dissuade the child from expressing those feelings. At some later time, parents can praise some particular aspect of the child that they value. Parents can wonder aloud about where a particularly appealing trait, characteristic, or behavior came from--suggesting, perhaps, that it came from the birth family or another family in which the child lived. They can also remark about how all of what has happened has helped the child be what he/she is. Children play for many reasons--to express their fears and feelings, to help work through past traumas, and to explore ways to deal with developmental issues. "Dressing up" and playing adult roles are ways that children practice "growing up." Foster and adoptive parents should encourage fantasy play but discourage the child from choosing a particular adult role early in life. Substitute parents should also discourage the child from viewing his/her foster or adoptive status as the distinguishing characteristic of his/her being and from forming his/her identity around that core. A foster or adoptive child is first and foremost a child with the same developmental needs as any child. However, the child's earlier experiences or foster or adoptive status complicates his/her life and may make meeting those needs more difficult. It should never, however, lead to defining him/her as a "foster child" or an "adoptive child" for the child's entire lifetime. The best way that foster and adoptive parents can help the child in their care develop a healthy identity is by serving as good role models. Children often unconsciously copy the behavior of the adults with whom they live. They are also trying to learn how to become an adult by watching and making conscious choices. One 10-year-old boy, who had never known his father, was living in his fifth foster home. One day his foster father asked him if he wondered what he was going to be like when he grew up. The boy said, "No, I know what I'm going to be like. I'll just remember the different foster fathers I've had and put together the best things about each to make myself." Helping Children Who Have Been Sexually AbusedA secure, stable family in which sexual behavior is appropriate and sexual boundaries are clear is the best foundation for the treatment of child sexual abuse. For caseworkers and prospective substitute parents, specialized training in helping children who have been sexually abused, however, is essential. Currently, most preservice foster and adoptive training programs are now directing attention to this subject. Training is important not only for the content and the skills that can be imparted, but because of the highly emotional nature of sexual abuse. The behavior of a sexually abused child affects foster and adoptive parents in at least four critical areas--the parent's own sexuality, the child's sexuality, the act of molestation, and the child's response to the molestation. Sound training aids foster and adoptive parents become more comfortable in discussing sexual abuse and accepting that part of a child's history. At the same time, training programs provide instruction in practical ways to deal with a child who has been sexually abused. The following are some basic guidelines for substitute parents to keep in mind when they attempt to discuss the abuse with their child:
The nature, frequency, onset, perpetrator, and duration of the sexual abuse all make a difference in terms of the meaning of the experience to the child. To the extent that foster or adoptive parents know about these circumstances, they can enhance their therapeutic endeavors. Frequently, details are not completely known or acknowledged. Because sexual abuse of most children takes place within the family setting, placement in a new family provides a healing milieu. There are some general principles about what that milieu needs to be to help most sexually abused children:
Safety and the Sexually Abused Child This manual has stressed the primary importance of providing a safe environment for children coming into care. This is especially important for a child who has been sexually abused because those adults who were responsible for protecting the child in the past have harmed him/her instead. The child must learn to understand that he/she is valued and that he/she can trust the adults in this new family to keep this a "safe home." This message should be emphasized verbally and behaviorally. Family Structure and the Sexually Abused Child A sexually abused child has usually lived either in a chaotic, dysfunctional family or in a family with unclear parental boundaries. The clearer and more reliable the structure in the new family, the greater the probability that the child will feel safe. Foster and adoptive parents should be able to explain clearly to the child the role each family member plays. They should reiterate this message any time the child seems confused or tries to blur the roles. It is likely that the rules that govern family behavior will also have to be repeated. A few simple and reasonable rules will make it easier for the child to adjust to the new family while developing a sense of safety. In particular, generational boundaries must be clearly drawn. Nothing offers a sexually abused child more protection than the reassurance that there are parental, child, and family activities. Only the latter activities are meant to include all family members. Parents should not try to participate with the child in all of his/her daily activities, and the child should not be not allowed to participate with the adults in all of their activities. Communication and the Sexually Abused Child A child who has been sexually abused has usually experienced situations in which communication was limited and in which a premium was placed on secrecy. In cases of incest, the child victim has been told to keep the sexual activity secret within the family structure, and in chaotic families, the child has been told to keep family secrets from the outside world. The child has been taught that open communication is harmful. Indeed, for some sexually abused children, their disclosure has actually resulted in the loss of their families. These children must learn that open communication offers opportunities both to resolve problems and to examine the pain of past experiences. Guilt and the Sexually Abused Child There are two particularly sensitive areas in working with a sexually abused child in placement--one is the child's guilt, and the other involves the complications of helping the child resolve being separated from the birth family. Guilt is a common response for victims of sexual abuse. They often feel that they share responsibility for the abuse and for what happens to the adult abuser. All too often, however, the response to a child who acknowledges this guilt is to simply reassure him/her that the adult perpetrator is responsible for the abuse. The intent is to cognitively and verbally explain the adult responsibility and thereby relieve the child of guilt. Unfortunately, such a response is seldom, if ever, very effective. Although the child is not legally or morally responsible for the abuse, he/she may feel responsible for what happened. Any reassurances to the contrary will not be heeded until the child's feelings of guilt have been accepted. A paradox central to treatment is that individuals cannot become anything other than what they are until they can accept what they are. The task of therapeutic intervention is to allow people to accept themselves at their worst so they can initiate change. To offer verbal reassurances to a victim of sexual abuse that he/she is not responsible for what happened is to deny the pain that the victim feels because he/she views him/herself as responsible. Before reassurance will have any impact, the child victim must feel that the helping adult understands his/her feelings of responsibility and guilt. That does not mean that the adult agrees with the child's perception, only that the adult validates it as the victim's perception. When the victim relates that he/she feels "dirty" and responsible for what has happened, the helping adult can respond by saying, "What a terrible feeling that must be for you." Once the feeling has been validated (often, after considerable repetition), the adult can introduce the cognitive "truth" with a comment such as, "I know that must be a very uncomfortable feeling for you. But children are not responsible for the actions of the adults with whom they live. You were sexually abused by an adult (or with the permission of the adult who should have been protecting you) and that is not your fault." Reconciling Sexual Abuse Victims with Their Families Because most sexual abuse involves a family member as the perpetrator, or at least as the responsible adult who condones such abuse, the reconciliation of an abused child with the birth family can be extremely difficult. This resolution involves the feelings of both the adults and the child. Again, professionals must understand that the child who is placed in care always lives in at least two families and that it is necessary for the child to integrate these two families before he/she can develop a sense of completeness and have a feeling of peace with him/herself. Thus, the child must make some sort of reconciliation with the birth family despite the child's abusive experience. The reconciliation does not have to include face-to-face contact, although this is often the best way for the feelings generated by the abuse to be settled. The foster or adoptive parent of the sexually abused child walks a fine line between acknowledging the ambivalent or angry feelings that the child has toward the family abuser while not condemning that parent as a person. It is essential that foster and adoptive parents resolve their own feelings about the adults who have abused the child; it is often necessary for them to seek support in accomplishing this difficult task. Special training concerning the issues involved in caring for a sexually abused child is essential for foster and adoptive parents. Such content is now a standard part of most foster parent training programs. In many communities, special programs directed by qualified trainers deal solely with the subject of sexual abuse. Increasingly, comprehensive training materials on sexual abuse have become readily available.32 Helping Drug-Exposed InfantsAs in sexual abuse, infant drug exposure is a subject in which foster and adoptive parents require special training. The drug scene is growing and constantly changing, and little is currently known about the long-range impact on infants prenatally exposed to drugs. However, most social service professionals are aware of many of the immediate consequences of drug exposure, and they can help foster and adoptive parents learn to effectively care for drug-exposed babies. Agency staff should be aware of the following eight general rules for the caring for such infants:
Many drug-exposed infants will present special medical or developmental problems depending on the type of prenatal substance abuse. The rates of preterm deliveries (birth at less than 37 weeks' gestation) for substance-exposed infants are significantly higher than for the general population.33 The care of some of these infants can be quite technically complex (e.g., a child with gastrointestinal problems that necessitate intravenous feedings), and specially trained foster or adoptive parents may be necessary.34 During the first 15 months of life, some drug-exposed infants may present feeding problems. Caretakers may find the following practices helpful:
In addition to preservice training and involvement with the professional team serving the child in their care, foster and adoptive parents of a drug-exposed child require additional agency support. Ongoing agency training designed especially for these parents is a good way to meet this need. This approach enables the parents to regularly learn new techniques and skills for helping the child and allows the parents to gain support from others who also care for children with special needs. Finally, it is important that foster and adoptive parents understand that Sudden Infant Death Syndrome (SIDS) can occur among drug-exposed infants in spite of excellent care and appropriate monitoring. Recent studies show that the incidence of SIDS is greater when young infants are placed face down in their cribs. Helping Other Medically Vulnerable ChildrenIn addition to children who are exposed to drugs or alcohol before birth, there are other children who are medically vulnerable, chronically ill, or developmentally disabled. Some children are born with congenital anomalies, disabilities, or susceptibilities to chronic illness; infections transmitted prenatally; low birth weights (perhaps as a result of the mother's young age or the failure of the mother to obtain adequate prenatal care); or birth injuries. Other children may become disabled as a result of an illness or accident later in childhood. Some children who are medically vulnerable, chronically ill, or developmentally disabled come into foster care or adoption in infancy because their birth parents voluntarily seek alternate care arrangements because they feel unable to parent their children. Other medically vulnerable older children are placed in care because the demands of their care cannot be met by their birth parents, some of whom may have abused or neglected these children. A substitute care provider for a child who is disabled and who has also been abused or neglected faces the difficult challenge of meeting the child's basic needs, helping the child master tasks and feelings related to his/her disability, helping the child overcome the trauma of abuse or neglect, and meeting the issues of substitute care. Helping Disabled Children in Foster Care and Adoption Foster and adoptive parents are the best resource for most children who are medically vulnerable, chronically ill, or developmentally disabled and who cannot be reared by their birth families. In all but the most serious situations, meeting the child's special caretaking needs and managing his/her medical regimen can be handled in a home situation if the caretaker is trained and supported by the agency and if community resources are available on an outpatient basis. Success depends on committed and capable foster or adoptive parents and a range of ancillary services offered by qualified, trained providers who are part of a well-managed, comprehensive plan. A child with disabilities who enters foster care or adoption after infancy usually has difficulty trusting his/her caretaker and developing a positive self-image. Many of these children have experienced placement in other homes, institutions, or hospitals. As a result of these earlier placements, the child's mastery of those developmental tasks that are possible within the limits of his/her disability have been delayed. For some children, the capacity to form trusting relationships has been severely damaged. Most perceive that their disability is the reason for their placement, and for many that may actually be a precipitating factor. Even more troubled is the child who knows that he/she has come into substitute care because he/she has been disabled due to an abusive act by his/her parents. Foster and adoptive parents caring for a child with a disability must help him/her feel safe, well cared for, and valued. Many of these children entering care may require immediate medical attention. A thorough assessment of the child's physical condition is essential both for planning and for helping the new family understand and accept the child's unique needs and limits. Each disabling condition brings its own set of complications for the child and his/her caretaker(s). For example, a child with cerebral palsy or spina bifida usually requires assistance with routine daily tasks such as eating, toileting, or mobility, and should benefit from physical, occupational and speech therapy. In contrast, usually a child with Downs Syndrome can be trained to manage routine caretaking tasks quite well but will require frequent medical attention as a result of one or more congenital abnormalities.37 Whatever the nature of their particular condition, there are a number of concerns that are shared in common among children who are medically vulnerable, chronically ill, or developmentally disabled. Most of these children must learn to cope with pain and to deal with some degree of incapacitation. Many have experienced hospital environments that generally were not geared toward children, and they have likely been subjected to intrusive and often unpleasant medical procedures. Some of these children must deal the side effects of medication. All face the future with uncertainty related to the issues of independence, self-care, social acceptance, further impairment, and possible early death. They must develop a self-image that can withstand inner doubts and external pressures.38 A person's self-image begins to form in infancy. The first view of self a child has is the reflection of his/her image in the eyes of caretaking adults. A child begins to perceive him/herself as worthwhile in response to the respect, love, and value the caretaker offers. Although a child's self-image continues to be influenced by the perceptions of others, as the child matures, this image is based less on those external perceptions and more on his/her own sense of achievement and competence. A healthy self-image depends on one's ability to feel that he/she has the capacity to cope both with current life situations and future events--by relying on internal resources and by making use of external resources when needed. Because a child who is medically vulnerable, chronically ill, or developmentally disabled soon learns to see that his/her body does not work as well as that of most other children, it is important that the adult caretaker reflects back to the child how much he/she is valued and loved. It is important, also, for the caretaker to teach the disabled child ways to manage his/her environment and feelings in order to help the child gain a growing sense of his/her own competence. Perhaps the hardest part of being a caretaker for a child who is medically vulnerable, chronically ill, or developmentally disabled is finding the balance between helping the child accept his/her limitations yet achieving the maximum within the restrictions imposed by his/her disabling condition. The caretaker must support the development of self-worth and the child's capacity to act in his/her best interests, yet manage not to place so great an emphasis on achievement that the child feels his/her value is determined by the capacity to please the adult caretaker(s). Substitute Care Providers for Disabled Children Just as there are a number of issues that are common among the wide range of disabled children, there are issues and concerns that are common among those who provide services to medically vulnerable, chronically ill, or disabled children. Unless they have had prior experience caring for a child with a similar condition, most prospective parents experience the following:
All of these concerns are valid and must be addressed in the recruitment, training, and ongoing support of foster and adoptive parents serving this group of children. The following four guiding principles may help agencies recruit and develop such parents and may help them succeed:
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