Adoption-Competent Therapy vs. Regular Therapy; What is the Difference?

Often, adoptive families are appropriately vigilant about their child’s development. They will seek out therapy when their child’s emotional or behavioral issues get in the way of their child’s typical development or if they become socially disruptive among friends or family.

In typical therapy, when a child is having struggles, a therapist views the child as the “canary in the cage” and will focus treatment on the family as a whole. Another common scenario is that the therapist will diagnose and treat the child without consideration of the child’s very early history. These two common approaches can be very effective for children with typical histories. However, if a child who has experienced neglect, abuse or trauma is evaluated and treated in this manner, does healing ever really occur?

All adopted children — of all ages — are at risk for changes in their brain’s chemistry and structure. These alterations don’t just go away with time and, if not effectively treated, can become increasingly problematic as a child grows older. A generalist therapist may conclude that the child is untreatable. Or the parents may repeatedly change therapists, keeping up hope that this next therapist will have the magic cure. This cycle of dashed hopes brings everyone down. Here are some common misunderstandings or misdiagnoses that our adopted children encounter in the mental/behavioral health profession.

Adopted children can have brain neurotransmitters that cause them to be too active or too inactive. In a nutshell, because their neurotransmitters are out of balance, nature cannot do its job of quickly calming their bodies after getting excited so they can get stuck being too excited. What do children who are too excited look like? A lot like John, who has difficulty paying attention in school, can’t keep track of two-step directions, can’ t get to sleep at night, can’t sit still, can’t keep his hands to himself, blurts out answers, interrupts, climbs on furniture, runs instead of walks, always in motion. If his parent described him like this, what do you think the diagnosis and treatment would be? Most of you I am sure thought ADHD and Ritalin. That is correct. A sticker chart is also probably thrown in too. At first, the novelty of the sticker chart helps, but it doesn’t last. Truthfully, the Ritalin could have a huge positive impact on the child’s behavior, but it doesn’t change the brain permanently. When the dose of Ritalin leaves the body, the child’s behavior reverts back and in some cases may even be worse as the medication is leaving his body. This is called the “rebound effect” from stimulants.

Let’s follow John farther in his life. When he gets to middle school, his dose of Ritalin is increased but he continues to have challenging behaviors. Also by now he knows he is different and not acceptable the way he is and this shatters any self-esteem he may have been hanging on to. He can become even more agitated and give up on himself. He becomes argumentative even about little things like what color is the sky. He will argue until the cows come home. He refuses to follow directions at home or will sassily ask his parents what will you give me if I do it? After more visits to the therapist and doctor, he will now have the additional diagnosis of Oppositional Defiant Disorder (ODD). He will be prescribed more medications and his parents will be advised to make him earn privileges and give him bigger consequences, even excluding him from family activities. Now he feels backed into a corner that he cannot get out of and he becomes angry, but deep down at his very core is a deep black pit of shame and grief. He lashes out in bigger ways. Fueled by neurotransmitters that are out of balance, his rage at everyone intensifies and he damages property. This time, his parents can’t take him to the doctor or therapist because the juvenile justice system has stepped in and now he is under their control and his diagnosis is Antisocial Personality Disorder. John has become a victim of a mental health system that didn’t understand his unique brain chemistry.

Another way John’s story could roll is this: John’s therapist and prescribing physician may be informed about the latest trend in adolescent mental health issues. They view his unpredictable behavior not as ODD but as being very rapid cycling of moods and give him the diagnosis of Bipolar Disorder and put him on yet another class of medications called mood stabilizers. Often, they will also throw in a med for sleep. This is a big time diagnosis that can affect future insurance coverage and some careers that he may want to pursue.

Another scenario is that Mary is quiet and obedient and never gets sick. Just a joy to parent, she doesn’t take up much of her parents’ time. As Mary gets older, her quietness is now seen as a problem; she can’t keep friends, she stays in her room all the time, she is irritable, worries about the smallest things, likes to sleep incessantly, and her eating habits have changed. Her parents at first chalked it up to teen behavior, but there was a creeping concern they couldn’t shake so they took her to their doctor. Depression. She is prescribed Prozac with instructions to see a therapist. The therapist reassures Mary’s parents that she has lots of experience with depressed teens and that everything will be OK in a few months. However, this doctor and therapist don’t realize just how altered Mary’s brain neurotransmitters are. It is not just her serotonin that is off balance. She may have fried her excitatory neurotransmitters and the serotonin in the Prozac is only going to help temporarily and then it will have to be increased. Down the road, she may also be a candidate for a mood stabilizer to supplement the antidepressant. Instead of becoming angry at everyone else, Mary’s deep black core of shame and grief is focused internally and she begins hurting herself.

Not all adopted kids who see a generalist for therapy end up this way. I am using some dramatic license, but only some. These scenarios are true and unfortunately, adoptees are over-represented nationally in the mental/behavioral health field. That means that the percentage of adoptees seeking mental/behavioral health services is much higher than the percentage of adoptees in the general population.

So what is a parent to do? Educate yourself on what makes a therapist adoption competent. It is not that they have treated adoptees in the past. It is not that they have friends who are adopted. It is not that they have colleagues who have expertise in adoption. A therapist who is adoption competent has completed accredited training in trauma-based adoption issues. They should not be using the old Reactive Attachment Disorder diagnosis. An adoption-competent therapist will be using a term similar to “Complex Developmental Trauma” or “Complex Developmental Disorder.” Trauma and neglect are both a huge piece of what adoptees have experienced. These two add up to huge changes in the brain that need a therapy that can create felt safety in the adoptee, which will calm the hyper-reactive fight, flight or freeze response they experience.

With both John and Mary, an adoption-competent therapist would ask for a detailed history of their life before adoption. She will be looking for quality of care, attachment and broken bonds, neglect and, of course, she will recognize that they have experienced some level of trauma just by the stress of international adoption. The therapist should have some sense of the bleak and barren existence children have in orphanages. Ideally, the therapist will be familiar with Karyn Purvis and the book The Connected Child, or Bruce Perry and Neurosequential therapy, or Theraplay. There are other effective therapies beyond these three.

Ultimately, the key is how the therapist conceptualizes your child’s behaviors. Does he see the behavior as old survival strategies that worked once but now are out of place, which is what you want, or does he say that your child is not capable of attaching? The therapist will want to include you in at least part of the sessions to give you additional skills in how to parent your child to help heal the trauma and create a sense of felt safety within the family. There may need to be changes in the number of activities your child is involved in or the way they are educated. Without treatment, trauma and grief can have a compounding effect on children, eventually reaching a critical mass where they are no longer able to accomplish all that they could before.

To find an adoption-competent therapist near you, visit the TCU Institute of Child Development and attach.org.

Abbie Smith, LCSW | Former Holt team member