Training for Adoption Competency - PowerPoint Presentation

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Training for Adoption Competency

Final Project: Adoption preparation for a youth presenting with complex traumaMichael Stempkovski, MA, LPC, NCCDecember 12, 2016

All contents ©2012 by Youth Villages, Inc. with all rights reserved.Slide2

Jayme Foster

13 year-old Caucasian female

Loves theatre and dance, reading, and is super-smart making all A’s and B’s in school

Great sense of humor and loves to laugh; good at puns

Has lived in at least 10 different places for at least 6 months in her life due to neglect, abuse and unexpected movesThinks that she will never have a mom or dad againHas more grit than she thinks

All contents ©2012 by Youth Villages, Inc. with all rights reserved.

Serenity is not freedom from the storm, but peace within the storm . . . Slide3
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Will a tree with no roots grow? What if there are no leaves?

Although Jayme and her pre-adoptive family are not currently living together, a formal Intent to Adopt was signed in October 2015 by both the pre-adoptive parents and the youth with the expectation that the adoption would be finalized in April 2016. However, the youth has a significant history of trauma exposure and grief and loss associated with her disrupted foster and adoptive placements as well as for the loss of her biological family (rights were terminated). This grief and associated trauma symptoms have manifest in serious behaviors including self-harm (cutting to arms, abdomen and inner thighs with a razor), a suicide attempt by overdose (resulted in a twenty-six day hospitalization in August 2016) and generalized anxiety about others that inhibits her ability to develop healthy, reciprocal relationships.

Imagine the tree through the seasons, in deepest winter with only the promise of spring . . .Slide7

Adoption AssessmentCompleted:●General Psycho-social (YV)

●Risk Trauma Assessment (YV)● Child Behavior Checklist● UCLA PTSD-RI DSM 5 (Child and Adolescent version)● Domains of Impairment in Children with Complex Trauma (Cook, et. al 2005)● Timeline of placements and moves● Genogram● Eco Map● Adaptation of Parenting Profile (DDP)Would be helpful to Complete:● Parenting Profile from DDP with Smiths● Vineland Adaptive Behavior Scale● NMT Brain MappingSlide8

Adoption Assessment

Adapted for use with Jayme to get her perspective on the pre-adoptive parents as it relates to her perception of herself versus how she would rate her perception of pre-adoptive mother and the pre-adoptive fatherWas very helpful as a conversation starter with the pre-adoptive family in terms of digging deeper into the source of dissatisfaction in the relationshipWas very helpful for the youth to give voice to her dissatisfaction with her relationship with the pre-adoptive mother; helped to evaluate the strengths in her relationship with pre-adoptive fatherWould be helpful to fully administer with pre-adoptive parents

to strengthen their co-parenting and to compensate with strengthsSlide9

Diagnosis and Symptom Criteria307.51 Bulimia Nervosa, mild309.81 Posttraumatic Stress Disorder with dissociative symptoms

300.02 Generalized Anxiety Disorder 244.9 Unspecified HypothyroidismThe youth reports binging on food in the cabinets when no one is around and later purging the contents to avoid gaining weight. The youth is very concerned about her personal appearance and would like to lose weight and live a healthier lifestyle. An immediate trigger to the youth’s suicide attempt in August 2016 was the youth binging, purging and then having negative thoughts about herself and her body. The youth reports often not being able to “feel” like other people do and that has been a trigger for self-harming by cutting on her thighs, upper torso and her forearms with glass, razors and/or a scalpel. The youth reported that her suicide attempt by overdose was because she was too nervous about cutting deep enough to bleed to death and that she did not want to hurt her body like; she just wanted to go to sleep and be able to stop worrying about everything. The youth purged the pills (seventeen) shortly after taking them and called her counselor because she was worried that she would die. Slide10

Severe physical abuse from the first adoptive mother in the form of being choked, hit, yelled at, demeaned, and threatened between the ages of 6 – 10 years old

Going a day or two at a time on “punishment” where food was intentionally withheld from her by the former adoptive mother Due to the extensive abuse, Jayme is very sensitive to strong emotions and “internal states” per her perspective when caregivers become loud and/or emotionalNot being able to fully voice her thoughts and feelings lead to the suicide attempt . . . Dislikes being touched by others but has difficulty telling others this - when triggered, Jayme dissociates . . . To feel again sometimes requires binging or cutting herself just a little bit . . . .

Frequent worrying thoughts about her relationships with others and whether or not she is being judged or labeled as well as frequent reports of feeling dissatisfied in relationships

Complex Trauma PresentationSlide11

Complex Trauma Presentation 

Ambiguous Loss:The youth’s multiple moves have resulted in numerous loyalties to caregivers who no longer have a relationship with Jayme.Following the suicide attempt, neither the youth nor her pre-adoptive parents were willing to finalize the adoption at that time due to tension in the relationship. Prioritization for specialized eating disorder treatment has resulted in a temporary replacement of the youth away from the pre-adoptive family – and Jayme blames herself.Jayme’s inaccurate and unhelpful thoughts about who is responsible for her multiple moves persists in her grief.

“I will never have a mom or dad again . . .”Slide12

●Implement safety interventions addressing recent suicide attempt with DBT skills● Coordinate and complete specialized eating disorder treatment● Complete a Loss Line & Loss Box for clarification and integration of the multiple losses

● Implement appropriate trauma treatment to address complex trauma symptoms● Utilize narrative therapy to enhance integration of losses that promotes actualization● Utilize CBT to address inaccurate/unhelpful thoughts and behaviors ● Focus on identity formation using strategies to improve healthy social connection● Focus on family rituals and routines that are inclusive for all family members● Improve communication in the family system to help her get more of what she wants● Encourage flexibility with the adoptive parents in their parenting strategiesShort summary of Treatment and Intervention Strategies to be applied: Slide13

Utilization of TAC Materials and Information with Jayme’s case: Dialectal Behavior Therapy (DBT) skill training to address Jayme’s suicide attempt as a primary issue in terms of safety and adoption.

DBT systematically teaches 5 skill sets: • Emotional regulation • Mindfulness • Interpersonal effectiveness • Distress tolerance • “Walking the middle path.”These skills are designed to treat specific problems common among suicidal adolescents and their families. For example, suicidal adolescents often experience a spike in emotions that leads to urges for ineffective behavior, such as attempting suicide or attacking another person. Mindfulness practices were utilized with Jayme to help cope with acceptance and change in terms of her power, voice and permanency options. Emotion regulation skills were utilized with Jayme to assist to measuring strong emotions, modulating them, and staying grounded in the present moment in session. Salsman, N.L. & Arthur, R. (2011). Adapting dialectical behavior therapy to help suicidal adolescents. Current Psychiatry, v.10, no.3, (March 2011), p.18-20, 22-23, 33 Slide14

Salsman, N.L. & Arthur, R. (2011). Adapting dialectical behavior therapy to help suicidal adolescents.

Current Psychiatry, v.10, no.3, (March 2011), p.18-20, 22-23, 33 .Utilization of TAC Materials and Information with Jayme’s case: Slide15

TAC Handout 3.2 Worksheet

: Seven Critical Elements of Preparing a Child for AdoptionEngaging the child

Started

with a

fresh life book based on the youth’s personal memories of where she has lived and developed that into a Life Line that included both happy memories and losses

Listening to the child’s words

Sought to hear the child’s words for each memory of a home; listening for the good,

the bad, the indifferent and the ugly; did

emotion coaching and labeling for complex emotions

Speaking the truth

Utilized

the truth to strengthen rapport and build trust

; did not avoid the difficult questions

; did not offer advice

; encouraged her to use her voice to find out the truth

when there where questions

Validating the child’s life story

Despite

what’s in the paperwork and what others have said –

her perspective was the most important

and validating that her thoughts and feelings about it were primary; honor grief and loss

Creating a safe place

Let her go at her own pace; incorporated snacks,

music, rhythmic activities such as throwing a soft ball back and forth, grounding and relaxation skills to manage her elevated stress response or work through dissociation as it occurred

Going back in time

Systematically

went back in a predictable, controlled manner to review progress on the life line and the memory box

; discussed responsibility for moves; discussed would/should/could haves

Recognizing pain as part of the process

Sat with the pain as

trauma reminders on innocuous cues came up; sought to

measure the amount of discomfort

; sought to reduce discomfort for increased mastery of trauma reminders; recognized success in overcoming; used cognitive coping and processing to enhance mastery;

validated that there are times she did not want to work on the adoption life story and memory box

Utilization of TAC Materials and Information with Jayme’s case:

Damiano

, J. (2002). Preparing children for permanency. Unpublished manuscript. Coordinator, Pennsylvania

statewide adoption network. Harrisburg, PA.Slide16

Utilization of TAC Materials and Information with Jayme’s case:

Began Implementing the 3-5-7 Model by Darla Henry, Ph.D●The 3-5-7 Model provides a specific approach for those who work and live with children in temporary care, remain in care and are making the transition to permanency through reunification, kinship care, adoption, or permanent legal custodianship.● For Jayme, addressing her grief of missing her biological mother and father, her attachment to her former adoptive father despite his severe sexual abuse of her older sister, and her loyalties to various caregivers that she has lived with throughout her life.● Clarification work was needed as she does not know much about when, where and most importantly why she has lived in so many homes and who was responsible for those moves – further work is still needed on this● Grief work for the loss of her baby sister whom she still fears for regarding safety

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Identity work on who she is, where she came from and where

she is goingSlide17

Utilization of TAC Materials and Information with Jayme’s case:

Answering the conceptual questions became the foundation for a new life book for Jayme and an “adoption story” to integrate the broken and jumbled pieces of her pastThe 3-5-7 Model: Five conceptual questions support the work of the three tasks and address the following: Who am I? -- identity formationWhat happened to me?--separation and loss; the grieving processWhere am I going?-- trust and safety in relationships; attachment cycleHow will I get there? -- recognizing those who will continue to provide support; relational permanencyWhen will I know I belong? -- feelings of safety, well-being and a readiness for future

Rituals and routines that enhance attachment to future family were discussed as part of how Jayme will know that she belongs

As a teen and a former adoptee, recognizing adoption as a lifelong process has been a barrier that we are still working on

When engagement and progress lull, going back to these critical questions helps to get back on trackSlide18

Clarity regarding their expectations for adoption:● Recognizing the pain of their infertility (disenfranchised grief for them)● Normalizing the parental feelings of those who adopt older teens

● Normalizing the response of their adopted daughter (Jayme’s older sister) ● Their perception is that the adoption of the youth’s older sister is a “failure” as the sister swiftly left the home to have contact with biological family, to live with her boyfriend and to attend college shortly after turning 18 years old. For pre-adoptive family, family counseling regarding their claiming of the youth:● Flexibility and warmth in their strategies to keep her safe● Discussing their comfort with their vulnerability as they transition from fostering to adopting Jayme● Pre-adoptive mother’s mother died by suicide – the youth’s recent suicide attempt is very triggering for her; need integration/actualization of this event● Pre-adoptive father is still in a role of wanting to adopt “just for his wife” – clarification work is needed for him on what it means to be an adoptive father in terms of his identity and relationship to Jayme

Utilization of TAC Materials and Information with Jayme’s

Pre-Adoptive Family

: Slide19

TAC Handout #4.2: Suggestions for Helping Children Manage Feelings of Ambiguous Loss Actualization:

Jayme has created a “loss box” that has been decorated and in it has things that represent her losses and things important to her. It would be amazing to have her share her box with the Smiths if she trusts them and feels safe enough to do so. They can then acknowledge her loss and recognize their part in her story and more importantly in her future. A lot of the items in the memory box are reminders for her and this will help the Smith’s to be mindful of the trauma that accompanies each transition to a different placement for Jayme. It would also honor the new start for the family as they start to create new Memories together as an adoptive family. Utilization of TAC Materials and Information with Jayme’s case:

Source: Boss, P. (1999). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University Press.

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Anticipated Challenges:Youth may not sign adoption finalization?Family may not sign adoption finalization?DCS and/or family team may determine that this is not an appropriate match?Youth may need to replace to another foster home in an urban setting to receive appropriate specialized treatment for her eating disorder?

What will be the plan for post-adoption services?Requested Feedback: How can I assist the youth and family in their adoption at this time? References:Child Welfare Information Gateway. Adoption and Stages of Development: Adolescence. https://www.childwelfare.gov/pubPDFs/f_stages.pdf Child Welfare Information Gateway. Life books.https://www.childwelfare.gov/topics/adoption/postplacement/lifebooks/ Cohen, J.A., Mannarino, A.P. & Deblinger

, E. (2012). Trauma-Focused Cognitive Behavioral Therapy for Children and Adolescents: Treatment Applications. New York, NY: Guilford Press

Henry, Darla. (2012). The 3-5-7 Model: Supporting the Work of Children, Youth and Families Toward Permanency. Camp Hill, PA. Sunbury Press.Linehan, M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York, NY. The Gilford Press. Perry, B. D. Memories of Fear: How the Brain Stores and Retrieves Physiologic States, Feelings, Behaviors and Thoughts from Traumatic Events. www.childtrauma.org*Some resources were sited on specific slides drawn from TAC curriculum resources