The memory is vivid. I am eight years old and I am screaming. I am hysterical in my room. I ache at a level that I cannot give words. Over and over again I cry that no one loves me and that I don’t fit. My father holds me. He cries while I cry. He tries to tell me that I am a handsome young boy and lovable and people do like me. He tells me he likes me. “You have to because you are my dad,” I cry. “You adopted me so you have to love me. No one who has a choice loves me.”
Insecurities are a normal part of childhood, but what I experienced was well beyond normal childhood angst, and it was coming at a very early age. In grade school and especially in junior high and high school I was racked with insecurities beyond anything you would typically see in any young person.
I had no faith in my ability to sustain a relationship. I would not have used those words but I “knew” it all the way to my core. I “knew” relationships would end if you just gave them a little bit of time. I did not trust anybody in my life with the possible exception of my father. I felt my grandparents, cousins, mother, even my siblings did not truly love me. I know now that I was wrong, but at the time that was my reality. It is only after many years of experience that I can look back and realize how tragically wrong I was.
With the benefits of education and experience, I better understand myself as a child. I see myself as having been hurt by the trauma of adoption and also by abuse in my early childhood. That trauma ruled the emotional centers of my brain and my brain then lied to me about unreal threats to security around me. I was stuck in a fight, flight, or freeze response.
I never got any professional help in my early childhood or at any time through my teen years. It was in my mid-20s before I began to sort out some of the emotions and fears that were driving me. I was able to heal through a number of very fortunate events. Call it divine intervention or dumb luck but it certainly was not a thoughtful application of trauma-informed therapy that changed me. That therapy didn’t exist at the time.
As I look back, I wonder, what help would have benefited me? Did I need psychiatric help, residential treatment, a good therapist? At what point were my trauma responses severe enough to warrant intervention? When and what help would have been beneficial?
To answer the questions of what help to give children and youth, and when to give it, we first must consider the levels of care that are available. There are four broad levels of intervention, listed below from least invasive to most invasive:
- Parent-educated care
- Outpatient therapeutic interventions
- Wilderness therapy and residential treatment
- Psychiatric hospitalization
Starting with parent-educated care, let’s consider each of these levels of intervention. We want to know what each level of care encompasses, when each level is appropriate and sufficient, and when to move up to a higher level of care.
Parent or guardian-educated care speaks to the notion that problems are handled at home but in an informed way. Too often parents believe they just need to love a child who experienced trauma and all will sort itself out. While well-meaning, this ignores a host of potential problems. Whether trauma issues are immediately discernible or not, parents or guardians simply must commit to understanding trauma and attachment theory. They have to commit to understanding what adverse childhood experiences do to the brain. They have to have some understanding of the best experiential ways to help traumatized kids.
Absent major behavioral disruptions, this is the place to start when there is any inkling that a problem may be around the corner. It probably would have been the perfect place for my parents to start when I was having troubles at such a young age. All children melt down at times. But usually there is an identifiable precursor to a meltdown.
Perhaps some friend at school has been repeatedly mean. Perhaps schoolwork is overwhelming and the child just cannot understand math. Maybe a younger sibling gets into a child’s personal belongings and destroys something.
Loss of emotional control in such settings is somewhat understandable. When there is not an identifiable precursor or the emotion is repeatedly and wildly disproportionate to the level of the irritation, that is the time to worry. My pain and hysteria was exactly this type of disproportionate response. When traumatized children act out emotionally and behaviorally beyond what peers do, parents need to intervene.
As parents seek to address trauma at home, here are some important points to keep in mind:
- Trauma and adverse experiences can have a life-long impact on a child’s brain, and can affect behaviors, relationships, social skills, mental and physical health, and more. Thinking about negative behaviors as a survival response to trauma or as a result of a re-wired brain can really help parents move from blaming their children to understanding their child.
- It’s important to focus on attachment first. Sometimes new parents get caught up in enforcing rules (such as making the bed, eating vegetables, or doing chores) or teaching life skills when instead it may be better to be hyper-focused on bonding with their child in the early days.
- When a child or youth is in extreme distress, it may be best to focus on your connection with the child and provide emotional comfort. Wait to have a conversation about why the child was so emotional until after the immediate crisis has passed.
First and foremost, parents who want to become more educated should pursue additional information in a number of ways. You can:
- Learn more about adverse childhood experiences (ACEs) at www.acestudy.org
- Explore the work of Dr. Dan Seigel (http://www.drdansiegel.com)
and Dr. Bruce Perry (http://childtrauma.org)
- Read the work of Dr. Daniel Hughes at www.danielhughes.org
- Join the Attachment and Trauma Network (www.attachmenttraumanetwork.org)
- Attend the NACAC conference
- Connect with other adoptive parents, including by joining a support group
The learning curve is steep but relatively short to get to a place of conversant knowledge. In many cases learning what to do from the best minds available will equip you to intervene early and change the course of your child’s life early.
Outpatient Therapeutic Interventions
There are two fundamental questions related to outpatient therapy: At what point do you need a therapist for your child? And how do you find a qualified therapist?
In answer to the first question, if you are out of your element and the education you have acquired is not making a noticeable impact after a few months, it’s time to find a therapist. Sooner rather than later is important. There is little chance of inflicting harm by finding a qualified, specialized therapist too early. My parents likely could have helped me without a therapist until I reached adolescence. Once I hit my teenage years I began to be involved in some risky behavior that should have triggered a therapist search. I was partying and becoming heavily involved with girls when I was much too young. Had my parents been more aware, individual and family therapy would have likely helped me reduce my problem behaviors.
A competent trauma-specialized therapist will help you in the education process and give your family solid interventions that will help at home. As soon as such a therapist becomes aware that you are not in need of their services, she will tell you. The key is that the therapist must be specialized. Don’t talk to just any generalist practitioner who says she knows adolescents or young children. Find someone with a trauma-informed practice. ATTACh.org has a list of registered clinicians across the country. If you join the Attachment and Trauma Network, scores of parents who have walked your road will have names they can suggest. If you belong to an adoption or foster care support group or are involved with an organization supporting adoptive or foster families, ask other adoptive and foster parents or service providers if they have a recommendation.
If you cannot find a therapist by asking for a recommendation, you should be able to find one by asking a few thoughtful questions. Use your newfound knowledge about trauma. What does the therapist know about the Adverse Childhood Experiences study? Is he well-versed in the work of Dr. Bruce Perry, Dr. Dan Hughes, or Dr. Dan Siegel? What specialty or experience does he have in adoption or foster care? Is she strengths-based and family-oriented? Is he using any evidence-based techniques that have been tried with young people who have experienced trauma and loss? Interview each potential therapist. When you are comfortable that the therapist knows much more than you, you can proceed.
Wilderness Therapy and Residential Treatment
Wilderness therapy and residential treatment are high impact and offer relatively long-term solutions. You might consider wilderness and residential options when outpatient therapy continues to fail, and your child’s behaviors and issues are too emotionally exhausting and maybe even threaten family security. Some combination of ongoing running away, defiance without resolution, failure at school, violence, threats to parents or other family members, sexual acting-out, or constant broken relationships may be an indication that wilderness therapy or residential treatment is needed.
Had I been in therapy my parents would have had data on my behavior and mental state. If I didn’t improve with therapy, and I began to act out more severely, wilderness and residential options should have come into play.
Wilderness therapy is anywhere from four to eight weeks (sometimes a bit more) and is outside of four walls, in nature, just as the name suggests. It might be in a desert or mountain setting. It can be winter or summer. Youth in these programs learn primitive survival skills or just community living in a challenging environment. At the end of the day, a trauma-focused wilderness program is going to try to teach trust and communication in a dynamic environment. These trust and communication experiences can be the building blocks for some very helpful family change.
Before you choose a wilderness program, make sure it is trauma-informed and has excellent reviews and recommendations from people you trust. Your goal is to find a place that has a healing practice, rather than a harsh boot camp that may further traumatize young people in pain.
Effective, trauma-informed residential treatment typically lasts at least 10 months. As the name implies, a child must leave home and live in the residential facility. It is a bit counter-intuitive to send a child who is struggling with trauma and attachment issues away to get treatment. However, in dire circumstances a setting is needed where all variables are controlled in the healing process. This is often best accomplished outside of the home. When a traumatized child’s behavior is life threatening, residential is needed.
As with outpatient therapy, find a specialist. Just as you would never go to a general practitioner for cancer treatment, you would never go to a generalist residential treatment center to tackle developmental trauma. A trauma-specialty residential setting will be very focused on the family system. Specialty residential treatment will require you to be on site often, to have weekly therapy, to have lots of contact with your child. The best residential will have transition planning that starts months before your child comes home. They will manage the transition home, likely with the residential therapist coming to your home to facilitate the transition.
Of course, wilderness programs and residential treatment are not cheap, with costs ranging up to $10,000 or more per month. Adoption subsidies, medical insurance, Medicaid, and even second mortgages might come into play. I must unfortunately acknowledge that some families simply cannot access this level of care.
Usually short-term, psychiatric hospitalization is a high-impact, invasive treatment option. The decision as to whether psychiatric hospitalization is needed is usually fairly straightforward. In my example at the beginning of this article, hospitalization would not have made sense. But if I had started cutting myself in the middle of that pain, that would have been a game changer. If I had described voices I was hearing telling me to hurt my mother that also would have immediately increased the needed level of intervention. Anything that looks like an immediate threat to the well being of the child or others is need for psychiatric care. If there is active suicidal ideation or a child pulls a weapon on a family member, it is usually time to hospitalize.
Decades ago, before residential treatment, psychiatric hospitalization was the final destination for most mental health and behavioral issues. Psychiatric hospitalization could last for months. Managed care changed that, and hospital stays decreased from half a year, to a few months, then to just a few weeks. These days hospitalization is typically for only a few days to a week, with the goal of stabilization only. No real therapy is done, and stabilization usually means changing medications to get behavior changes. Once a child is stabilized, it is usually time to move into a residential or wilderness setting or to access therapeutic supports in the home or community.
I struggled needlessly for years. My healing timeline could have been dramatically shortened if my parents had known where to start. My hope is that this article will guide you to make appropriate decisions at the appropriate time. Remember that others have walked this path before you. Don’t believe for a minute that your situation won’t get better. Don’t try to find help without reaching out to others who have gone before you. Using the resources mentioned above you can find help. You can find hope. Your child can heal.