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Adoption-Telling the Child about Rape, Incest and Other Birth Circumstances
Adoption: Telling the Child about Rape, Incest and Other Birth Circumstances - 10 CEUs

Section 26
Is there Science behind Adoption Attachment Theories?

CEU Question 26 | CEU Answer Booklet | Table of Contents | Adoption
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Towards Evidence-based Approaches to Meeting the Needs of Adoptive and Foster Parents
Attachment therapies apparently address the desire of parents to find a way to improve lifelong outcomes for their children, especially a way that offers a past explanation and does not heavily emphasize changing their current interactions with, and expectations of, their children. This is not to suggest that adoptive and foster parents are not willing to make substantial sacrifices for their children – there is much evidence in qualitative research studies that they are (Howe 1997; Thoburn et al. 2000). However, they may be reluctant to sharply modify parenting practices that have worked with other children and that cannot be reasonably said to have created their child’s problem.

Parents, and professionals, often come to believe that the attachment paradigm is a well-tested one and may not know of the limited scientific basis of attachment therapies or the possibilities of other approaches. The concluding section of this paper endeavors to propose alternatives to the current over-reliance on attachment theory and therapies.

Painful Sense of Loss From Lack of Closeness and Fear for Child’s Social Development
Parents who are attracted by attachment therapies may feel hopeless about the present and the future. As discussed earlier, RAD has become a commonly used label to describe a child who is acting in ways that are discordant with parental expectations. Although some of these children are seriously troubled, attachment labels and therapy are also used for children who are difficult for parents to care for and become difficult to care about. The ability to relate to another person is a skill that runs on a long continuum, a skill that can change and be demonstrated more or less well depending on the context. As such, classifications such as ‘attachment disordered’ do not help to promote openness in parents about their children’s development nor hope about their future well-being. Parents of troubled children need to find effective interventions to deal with children’s behaviors within the current context of the adoptive family.

Although adoptive parents, who are often well-educated, may be seeking a science-based response to the perceived problems of their children, our review identified little science to support the notion that ‘attachment’ issues cause these behaviors. Whereas some of the children who receive attachment therapy have experienced seriously substandard and harmful parenting, the impact of these experiences on their current behavior may not be mediated through attachment. Indeed, the discussion of attachment is often circular – the child has difficulties in social relationships (attachment), and therefore s/he has attachment disorder. There may be many reasons for difficulties in social relationships that are largely independent of attachment problems. Indeed, studies from the USA and Sweden find that lower middle class families have more success as adoptive parents than highly educated and employed families (Barth & Berry 1988; Hjern & Vinnerljung 2002); findings from the UK are less clear. The US and Swedish findings may be explained by a too singular concern about the educational and social attainment of their children, rather than difficulties in attachment (Barth 2002).

Children’s externalizing problems may also contribute to parent–child alienation, as parents struggle with the challenge of providing a consistent, strong, positive response to the negative actions of their children. Indeed, the RAD diagnosis includes reference to a range of conduct problems that must co-occur with the other criteria discussed above. Thus, adopted children might respond well to interventions for general groups of conduct-disordered children. Nevertheless, many adoptive parents incorporate factors external to their parent–child interactions, including genetic and bio-social trauma, and perceive their family’s interactions as being substantively different than those in a biological family. They may conclude, not without some good reason, that the conduct problems of their children are therefore not likely to be amenable to treatments that do not acknowledge such causes.

Therapists who take too strict a behavioral position – that is, that the parents caused the problems by inadvertently reinforcing poor behavior and failing to reward positive behavior – may agitate parents’ legitimate concerns and leave them responding to the therapeutic experience as adoption insensitive (Smith & Howard 1999). This strict behavioral position need not, however, be the sole thrust of a social and cognitive skills intervention which must also accommodate pre-existing differences in children and recognize the many paths that families follow to points of high conflict. Interventions developed for young children in foster care (Dozier et al. 2002) as well as for older children in foster home care (e.g. Pallett et al. 2002; Chamberlain 2003; Beek & Schofield 2004; Sinclair et al. 2004a,b) have shown that foster parents value the assistance they receive in managing interpersonal interactions with children and in developing sound and satisfying strategies for addressing the problem behaviors that interfere with parent–child satisfaction. These interventions are conducted in the context of a support group of foster parents and a trusting and partnership-based relationship with a social worker, which also allows family members to gain some perspective about the challenges of parenting. These groups also help families assiduously identify the gains that are being made, rather than to focus on the continued discrepancy between what parents hope for and what they get.

A newer generation of interventions to address children’s problems, arising from anxiety and trauma (e.g. Kolko & Swenson 2002), often include parents in therapeutic roles. They do not, however, forcefully address the parent–child relationship. Evidence-based interventions for conduct disorders do not necessarily posit parent–child relationship disorders. That is, these interventions are intended to increase positive parental supervision of children, minimize children’s associations with antisocial peers, provide consistent discipline, and increase encouragement of youth (Chamberlain 2003). Such interventions may lead to a reduction in children’s problem behaviors and parents feeling closer to their children, but these approaches require significant changes in parenting behavior (Patterson et al. 2002). These interventions may only gradually – if at all – increase mutuality of feeling between parents and children. For parents who cannot tolerate prolonged tensions between themselves and their children, attachment therapy promises a faster resolution – a promise without evidence behind it. We would argue that it is the parent–child relationship that is the central reason for adoptive parents to come to therapy. Evidence-based interventions that address parental–child relationships and the parent’s expectations about them – e.g. Functional Family Therapy (Alexander & Parsons 1997) – also deserve testing with adoptive families.

The Desire for a Scientifically Sound Framework That Addresses Parent-Child Interactions
Attachment-based theories were never intended as an explanation of children’s underlying temperament, yet temperamental differences clearly influence differential engagement in social relationships. Underlying temperament has been implicated in the two very different behavior patterns associated with RAD: one highly inhibited and one disinhibited (Zeanah & Fox 2004). Although there is not a consistent set of findings about attachment and temperament, the possibility certainly exists that temperament is primarily responsible for the behavior of children who have limited skills or interest in social relationships with their parents. The range of children’s temperaments is extensive. The current misunderstanding of children with difficult temperaments echoes the historical response to autism. The explanation and treatment of autism was once dominated by psychoanalytic treatments that focused on a Freudian etiology of children’s autism and gave no stock to any possibility of underlying organic issues, and that resulted in lengthy segregation of autistic children into residential treatment (Bettleheim 1967). Perhaps in a similarly flawed response, attachment therapists now assume that the reasons for the disorder lie solely in the children’s exposure to maltreatment or limited early opportunities to develop social relationships, and the basic assumption is the same. The child’s development is conceived of as limited and frozen for entirely psychological reasons. Interventions based on social and cognitive learning theories offer additional and (at least in general populations) more tested interventions – indeed, the bulk of interventions identified as promising with abused and neglected children and children with conduct problems have a common social learning ancestry (Barth et al. 2005).

Finally, children’s transitions into foster and adoptive families may be positively viewed through a life course perspective. This empirically grounded theoretical orientation considers the importance of social constraints and timing on human development, as well as of the connections between individual lives and social relationships, and of varying historical and contextual circumstances (Elder 1996). In the case of foster and adopted children, who likely experience a radical and often comprehensive change in environment, the effect of positive parenting may drastically alter the developmental trajectories of these children. Elder (1998) states that:

. . . early transitions can have enduring consequences by affecting subsequent transitions, even after many years and decades have passed. They do so, in part, through behavioral consequences that set in motion ‘cumulative advantages and disadvantages’. (p. 7)

Through the transition to a strong family setting, children have the opportunity to accumulate advantages with the potential to affect lifelong outcomes. It is critical that interventions target these windows of opportunity in a manner that is developmentally sensitive and appropriate to the context and culture of the family.

Conclusion: Towards More Evidence-based Approaches to Helping Troubled Adoptive and Foster Families
Interventions with children experiencing conduct disorders have matured substantially during the last decade, and a variety of US federal and state governmental ‘blueprints’ and scientific papers (e.g. Weisz et al. 2005) have identified a core group with the highest levels of scientific support. Most of this work is with biological families and, as yet, the evidence of efficacy with children who have experienced maltreatment is limited. These interventions are The Incredible Years (Webster-Stratton & Hammond 1997), Parent Management Training (Reid & Kavanagh 1985), Multisystemic Therapy (Hengeller et al. 1998), Parent Child Interaction Therapy (Eyberg et al. 2001; Chaffin et al. 2004) and Functional Family Therapy (Alexander & Parsons 1997). Other parent intervention programs with substantial use and some empirical evidence include Parenting Wisely (Gordon & Stanar 2003) and Common Sense Parenting (Thompson et al. 1996; Barnes & York 2001). The evidence base for treating children with a variety of different conditions is developing in the research world (see for example the work of Judith Cohen, John Weisz, David Kolko, and Scott Hengeller). In the UK, psychologists, psychiatrists and social workers are involved in the development of evidence-based treatments (for example, Stephen Scott and William Yule). There is a risk that adoption workers will miss out on these developments because of their immersion in attachment language and concepts. This appears to be excluding them, and their clients, from benefiting from a wider range of theories and approaches to treatment.

Greater awareness is needed that other promising interventions exist and are being vigorously tested for their ability to enhance parent–child relationships among maltreated children (Barth et al. 2005).

Whereas these interventions may not, ultimately, be quite as successful with the full spectrum of children having withdrawn or rejecting temperaments, the paradigm for developing such interventions is available (Dozier et al. 2002; Chamberlain 2003). Satisfactory parent–child social relationships depend on many factors and may require a broad family and school-focused response. Interventions that have addressed these issues for children developing or showing conduct disorders should be adaptable to interventions with adoptive and foster families.

Professionals who approach their work from the paradigm of attachment theories may incorporate ideas from earlier work to integrate an understanding of the attachment between family members and behavioral interventions that help to modify parent–child relationships (Greenberg & Speltz 1988; Speltz 1990; Scott 2003). More recently, a rigorous clinical trial has been implemented in the USA to assess the effectiveness of the integration of attachment-focused interventions and social learning theory for caregivers and young children in foster care (Dozier et al. 2002).

This innovation offers promise for the development of science-based interventions that address children’s social behavior and parents’ concerns. Ross Thompson, a leading scholar in the area of attachment and development, and colleagues (Thompson 2000; Thompson & Raikes 2003) conclude that understanding children’s working models of attachment security can be useful but that cognizance of a broader set of influences on children’s social relationships is also critical. These include strategies for negotiating conflict and establishing cooperation. The field needs to recognize the elements of security that parents and professionals have found in attachment theory and therapies, but also be cognizant of the importance of engendering a broader set of evidence-based interventions to help adoptive and foster families in distress.
- Barth, Richard, Crea, Thomas, John, Karen, Thoburn, June & David Quinton; Beyond attachment theory and therapy: towards sensitive and evidence-based interventions with foster and adoptive families in distress; Child & Family Social Work; Nov 2005; Vol. 10; Issue 4.
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #12
The preceding section contained information about evidence-based approaches to meeting the needs of adoptive and foster parents.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 26
According to Barth et al., what parental desires do attachment therapies address? Record the letter of the correct answer the CEU Answer Booklet.

 
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The article above contains foundational information. Articles below contain optional updates.
Improving well-being and outcomes for looked after children in Wales: a context sensitive review of interventions
Improving outcomes for looked after children and young people has been a longstanding concern in Wales. This article reports the findings of a scoping study which sought to identify interventions aimed at improving outcomes for looked after children that are effective or promising. The study was commissioned by an independent funding body to inform a £5 million investment programme for Wales. It comprised a rapid review of literature, informed through consultation with an expert advisory panel and groups of young people who had been in care. The article outlines the rapid review method, provides details of shortlisted interventions and describes the interventions subsequently approved for investment. It concludes that although there are many promising interventions which address the factors associated with poor outcomes for looked after children, the evidence base is weak. It is argued that decision-making on interventions should be informed by appraisal of the empirical evidence available, but should also be guided by professional judgement that considers the needs, priorities and preferences of service users, carers, practitioners and policy-makers.
Reflections on the non-accidental death of a foster carer
This article is a case study and analysis of the death of a foster carer in Scotland at the hands of the child for whom she was caring. The death was the subject of a Fatal Accident and Sudden Deaths Inquiry in 2015. The case study explores whether or not this was a unique case, its messages for understanding child on parent violence, the adequacy of foster carer training, approval for blanket or specific age ranges, information about children provided to foster carers, meeting the needs of traumatised children and birth family contact when children have access to social networking sites. It considers if there are lessons that can and should be drawn from this case.
A comparison of parenting stress and childrens internalising, externalising and attachment-related behaviour difficulties in UK adoptive and non-adoptive families
This study aimed to increase understanding of the impact of the parenting task in a representative sample of adoptive and non-adoptive parents in the UK. Cross-sectional data from two UK samples were collected: (1) 86 adoptive parents and (2) 167 biological parents, of children aged 3–11 years. Parenting stress and parent-reported child internalising, externalising and attachment-related behaviour difficulties were assessed via online questionnaires. Data were analysed using descriptive statistics, correlation and analysis of covariance. Compared with their biological counterparts, adoptive parents described higher parenting stress, which was explained by their reports of greater child difficulties, including attachment-related problems. The same was found for biological parents but with lower levels of stress and child difficulties. Thus, the unique nature of the adoptive parenting task indicates that parenting stress should be considered a risk factor when difficulties are present in adoptive families. Furthermore, service thresholds may be better informed by this understanding, particularly as this study found that while just under half of children had high levels of difficulties, under one-third of parents reported receiving services.
Culturally sensitive child placement: key findings from a survey of looked after children in foster and residential care in Ibadan, Nigeria
The quality of the caregiver–child relationship is key to the well-being of children but assumptions based on research in western countries about the benefits of different types of substitute care may be questionable when applied elsewhere. This study assessed the quality of caregiver–child relationships and their association with child abuse in foster and residential care in Nigeria. The findings are relevant to European and North American countries as 4% of those looked after and 6% of care entrants in England are of African heritage and it is too easy to draw wrong conclusions about the care they might have received in their own countries. The study scrutinised 314 children aged 7–17 years from foster (157) and residential care settings (157) and assessed the caregiver–child relationship using the Positive Relationship Scale. The child abuse measure covered physical, sexual and emotional components and aggregated these into a single score. The subsequent analysis explored differences in child abuse between foster and residential care and the significance of other factors influencing levels of child abuse. It was found that the children in residential care had more positive relationships with caregivers than did those in foster care, even though abuse occurred in both settings. There were no gender differences in experiences of child abuse in either setting but children under the age of 12 were significantly more likely to have been abused while in care than those over this age. For children in residential care, age was the most significant factor associated with abuse. As these findings provide a perspective on children in substitute care in a West African city, they may be useful to social workers elsewhere who are responsible for children of African heritage, as they suggest that abuse often occurs in foster homes and that child–carer relationships in residential establishments can be good.

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