Kara Carnes-Holt’s daughter had one wish on her fifth birthday. “I wish that this mommy and daddy keep me forever,” the little girl said as she blew out the candles on her cake.

Hearing her wish, Carnes-Holt and her husband assured their daughter they were going to keep her forever. They became foster parents to their daughter when she was 4, and the adoption was finalized when she was 5.

Their daughter is now 11, but reflecting on that wish still breaks Carnes-Holt’s heart. “A child who is not adopted doesn’t have that fear,” says Carnes-Holt, an assistant professor in the counseling program at the University of Wyoming who works with adopted children and families through the university-based clinic. “I wish that my child didn’t have that fear. A child at 5 should never have to worry that they’re not going to have a mommy and daddy forever. No child should have to worry about that.”

In the years since their daughter joined their family, Carnes-Holt says they’ve concentrated on creating new family traditions, taking lots of family pictures and celebrating the anniversary of the day their daughter was adopted.

Although her daughter no longer fears that her parents might leave her, Carnes-Holt says it takes time for foster children and adopted children to heal. “You can tell a child [that you’ll keep them forever], but they also have to live it for a while,” says Carnes-Holt, a member of the American Counseling Association. “It’s just going to take some time for them to believe it. They have to feel that they can be part of the family and that they’re loved. Actions are stronger than words.”

Carnes-Holt says her daughter suffered emotional abuse and was frequently neglected by her birth family. She was in a therapeutic foster home prior to coming to live with the Carnes-Holts and struggled upon joining their family. Carnes-Holt believes rebounding from past trauma and loss of caregivers is a long-term healing process for foster children and adopted children, and she contends that the primary healing comes via new relationships. “In counseling, we focus on interventions and techniques, but the most healing component is a long-standing, unconditional relationship with someone,” she says. “That provides the most healing dynamic of anything we can do [as counselors].”

There are three different “tracks” for children through the foster care and adoption system, Carnes-Holt explains. First is foster care only, in which a child is removed from the home and placed temporarily with a foster family by the child services system. In this scenario, the goal remains to reunite the child with his or her birth family. If that doesn’t work, it becomes a foster-to-adopt situation, Carnes-Holt says. In this scenario, the parental rights of the birth parents are terminated, and the foster family is often given the first chance to adopt the child. With the third track, adoption only, parental rights have already been terminated. The child lives for a period of time with a family in a foster situation until the adoption can be finalized.

Michelle Zeilman works as a counselor with foster children through a nonprofit organization in St. Louis. A few decades ago, permanent foster care was more of the norm, she says. But after the Adoption and Safe Families Act was passed in 1997, the foster care system was tasked with either working toward reunification of children and their birth families or finding adoptive placements, says Zeilman, who is also an adjunct professor at the University of Missouri-St. Louis.

Counselors might encounter or seek out foster children, adopted children and their families as clients in a variety of ways. For instance, Carnes-Holt says, counselors might work with foster children through a community mental health agency, a private practice that accepts Medicaid or a children’s home.

Laura Hoskins, an ACA member who runs a private practice in Brattleboro, Vt., and specializes in working with adopted children and their families, says counselors can first seek out work with agencies that support those families. After gaining the necessary expertise, counselors can consider setting up a private practice and specializing, she says.

Although closely related, working with foster children and their families can be a different experience for counselors than working with adopted children and their families, according to Carnes-Holt. “[With] foster families, you are working more with external systems such as Child Protective Services,” she says. “Oftentimes, the outcome and future for the child may not be determined, so treatment planning and preparing the child for the future can be difficult. You also do not have control over many decisions that are being made for that child, such as visitation, reunification, termination of parental rights, etc. You can make recommendations, but those are not always followed, although you can always try to be the advocate.”

“For adoptive families,” Carnes-Holt continues, “you are working more on developing a strong sense of connection and attachment in the family system, working to create a sense of permanency for the child and integration within [his or her] new setting. You are working to help the parent and child create an attuned relationship that lays the foundation for increased chances of long-term success for the family.”

Wounds from the past

These counselors say both foster children and adopted children often deal with issues of attachment and trauma. As a result of their traumatic histories, Zeilman says, these children sometimes exhibit acting-out behaviors, aggression, withdrawal or hypervigilance. And although focus is often placed on the trauma and abuse history of the child, Zeilman says another important aspect often gets overlooked: the trauma the child experiences being removed from one home and trying to assimilate into a new family system.

Fitting in with a new family can be challenging for many foster children, Zeilman says. For instance, children from abusive backgrounds might have different ideas about how family relationships are defined and look, and they sometimes have developed certain behaviors that helped them survive in the past. Those behaviors can become problematic in their new foster home, Zeilman says. “As a therapist, the view I take is that I should be able to work wherever the needs are at that time,” she says. “I might sit down with the foster family and child and talk about what the expectations are in this new system and how we can help the child understand that things work differently here.”

Likewise, hypervigilance among foster children is also often rooted in their traumatic experiences, Carnes-Holt says, and it can appear similar to attention-deficit/hyperactivity disorder. Peer interaction can also be difficult for foster kids, she says, and they might exhibit oppositional behaviors and an extreme need for control because of the loss of control they otherwise feel in their lives.

It can be difficult for foster parents to see the child struggling, but Carnes-Holt says they shouldn’t take it personally. She explains that the child is simply working to process all of his or her previous experiences. “It’s hard when you try day in and day out to connect [with the child] and you still get opposition and struggles at school and at home,” she says. “[Foster parents] have to learn to make it through the long haul and create the relationship and separate out those behaviors as symptoms of what [the child has] been through. It’s not about them hating you.”

As for the birth parents in a foster situation, Carnes-Holt says they need to take some ownership of what has happened and work to reestablish the child’s trust because that link has been damaged. It takes a lot to say, “I messed up, and I can do better,” she notes, but just because parents apologize doesn’t mean that the level of trust will be rebuilt immediately. A counselor might work with the birth parents to deal with their own issues, to avoid placing blame on external systems and to prove themselves trustworthy to their child again, Carnes-Holt says.

When working with foster children, understanding child development is critically important, Zeilman says. “As these children reach new developmental phases, they tend to reprocess their situation — the abuse/neglect, removal from the birth family, placements, identity, etc. This may bring new issues and problems that these children will need to work through. Therapy may need to be revisited at different times as the child develops.”

In Carnes-Holt’s view, the primary role of the counselor when working with a foster child is to be the advocate for the child, working with the child services system to secure whatever he or she needs to live a safe and happy life. Depending on the plan the system dictates for the child, a counselor might conduct individual counseling with the child or conduct family counseling with the birth family and child, the foster family and child, or the potential adoptive family and child.

Settling into a new home

It’s commonly thought that children adopted as infants are more likely to have an easier time adapting and attaching to an adoptive family, Carnes-Holt says. But even for those children adopted almost immediately after birth, an attachment had been formed while the biological mother carried the baby, Carnes-Holt points out, meaning there was also a break in the attachment between the child and the primary caregiver.

Although older children who are adopted are often considered more at risk for issues such as learning disabilities, attention issues and attachment struggles, Carnes-Holt says it’s not necessarily their age but more so their experiences that dictate how they will manage in a new family. A 5-year-old who lived in a stable family with the same mom and dad but gets adopted after her parents die in a car accident might fare better than a 2-year-old who has been in multiple foster homes, Carnes-Holt says. She acknowledges, however, that the older children are, the more chances they have had to experience traumas.

Echoing Zeilman’s thoughts concerning foster children, Hoskins says that during typical developmental stages of growth, the prospect of adoption can add a wrinkle to what is already a challenging time. “The easiest example to illustrate this is the task of teenage adolescents to individuate and determine who they are and where they fit in — in their family, the world, anywhere,” says Hoskins, who has two adopted children. “For a child who may have had no contact with birth parents while growing up, this can be a particularly challenging time period.”

Another hurdle for children who have been adopted, particularly internationally, is the potential stigma or challenge of being the only person in their family, school or even town with a particular skin color, Hoskins says. “While this is not usually a difficult issue for preschool-age children, it can become a more significant issue as the child matures and he or she begins to notice the difference and becomes confused about whether this is their family. And peers may use [the difference] to taunt.”

Carnes-Holt says adopted children can struggle with the idea of the difference between adopted and biological children. Counselors can support the family by helping the parents understand how best to explain the difference, she says. For example, the parents might tell the child that there are many ways to make a family and that they are connected by their hearts. She says it’s important not to tell a child, “We couldn’t have a baby, so we decided to adopt,” because this can imply adoption was the less-favorable option.

One welcome difference Hoskins notices now in comparison with years past is that the stigma of adoption has decreased and more parents are being open with their children about their histories. “A generation ago, it was not uncommon for parents to keep from their child the fact of their adoption,” she says. “The child may not have learned about it until an extended relative said something unknowingly, the child discovered their adoptive state when needing to produce their birth certificate for legal purposes of some kind or even [found] documents revealing the truth of their adoption after their adoptive parents had died. Being adopted was considered a much greater stigma in generations past than it is now. Much of the adoption literature encourages parents to begin telling their child their adoption story at a developmentally appropriate level as soon as the child joins the family. Creating an adoption book or a life story book is another way families today are encouraged to celebrate the fact of their child’s adoption.”

The issues faced by adoptive parents can vary based on the circumstances surrounding the adoption of their child, Hoskins says. If the adoption is classified as “open,” meaning the potential exists for a continuing relationship with the birth parent or parents, determining how close that relationship will be is a challenge for everyone involved, Hoskins says. If the adoptive parents were unable to have children biologically, they may also be struggling with feelings of shame or unworthiness, even after an adopted child has joined their family, she says.

When the child is acting out, it can be isolating and scary for foster or adoptive parents, Carnes-Holt says. These parents have a tendency to feel ashamed, to question whether they are providing a good enough home and to believe that they are the only family struggling, she says. On top of that, they often don’t know where to go for help, Carnes-Holt adds. If counselors are working with prospective adoptive or foster parents, it is important to validate that it is a wonderful thing that they are considering doing, Carnes-Holt says, but at the same time, to prepare them to potentially encounter some negative behaviors on the part of the child.

“Adoptive parents may be dealing with the challenging behavior of a child with reactive attachment disorder (RAD) or posttraumatic stress disorder (PTSD) due to their early life experiences,” Hoskins says. “To attempt managing these challenging behaviors on their own would likely only lead to frustration and an unhappy family. Counselors can best help these families by, at most, obtaining training regarding adoptive parenting, RAD and PTSD in adopted children and, at least, reading recommended books on these issues. Encouraging families to become involved in or actually offering a support group for adoptive parents can be extremely helpful.”

For her part, Carnes-Holt believes RAD is a rare diagnosis that at times can be overused by mental health professionals. Being pulled away from a primary caregiver disrupts an attachment and is traumatic, but having a normal reaction to those events doesn’t necessarily indicate a disorder, she says.

Helping children heal

According to these counselors, many of the same counseling techniques work with foster children and adopted children. Zeilman points to cognitive behavioral therapy (CBT) techniques as being supported by research. Once the child is in a more stable situation, trauma-focused CBT can also be helpful, she says. Many counselors also use solution-focused techniques, Zeilman adds, because the counselor and child can pick a problem and figure out a solution for it, which helps to stabilize the child’s environment.

Carnes-Holt, a child-centered play therapist, says the model of child-parent relationship therapy is helpful in teaching parents the basic skills and philosophy of child-centered play therapy so they can use it with their children. Parents learn reflection of feelings, therapeutic limit setting, esteem-building statements, choice giving and more, she says. Child-centered play therapy offers an unconditional relationship with the child, Carnes-Holt explains, and the goal of child-parent relationship therapy is to encourage parents to offer that kind of relationship as well.

The reason child-centered play therapy is so effective both with foster children and adopted children is because these children have lost a substantial amount of control in their lives, Carnes-Holt says. This mode of therapy allows the child to be in control and allows for therapy to happen at the child’s pace. “Children have it within themselves to heal,” she says. “They’ll take the counselor where they need to go.” Theraplay, parent-child interaction therapy and dyadic developmental psychotherapy are three other commonly used techniques with this population, according to Carnes-Holt. All three, however, are more directive than child-centered play therapy, she says.

Hoskins points to a handful of clinicians who have written books, conducted research or offer trainings relevant to working with adopted and foster children. Dan Hughes has authored several books on working with attachment-disordered children and families and also leads workshops and trainings for parents and clinicians. Hoskins also recommends Nancy L. Thomas’ book When Love Is Not Enough: A Guide to Parenting Children With RAD-Reactive Attachment Disorder. Bruce Perry is another well-known expert who has done research on the effects of trauma on early brain development. He founded the ChildTrauma Academy in Houston.

Carnes-Holt says more and more research is being done to understand what trauma and attachment do to the brain. As answers continue to surface, she believes counselors and parents will come to recognize that these children are not intentionally trying to be difficult, but that their brains have been shaped differently because of past experiences. Many of these children’s behaviors are fear-based, she says, not based in willful defiance or manipulation. And although it takes time to heal the brain, Carnes-Holt says stable, ongoing relationships can go a long way in doing just that.

It’s crucial that any counselor working with this population also learns to work systemically, Carnes-Holt says. Counselor education programs often prepare counselors to focus on individual and family therapy, she says, but counselors working with foster and adopted children and their families must know how to collaborate effectively with agencies, schools, doctors and many other variables in the equation.

It can be challenging for counselors when they feel pressure to produce results in a certain period of time, Carnes-Holt adds. For instance, the foster care system might decide a child should begin having visits with his or her mother again even though the counselor doesn’t think the child is ready for that step yet. “Somehow, you have to collaborate to move forward,” she says.

Training is a must for any counselor working with foster and adopted children and their families, Hoskins says. “Please have focused training or supervision in this field, because it is not simply counseling with the added flavor of adoption,” she emphasizes. In addition to reading recommended books, it is even more helpful to take workshops and earn continuing education from trainings provided by clinicians who are respected in the field, Hoskins says. “Knowing adopted families personally can make a huge difference, and actually being an adopted parent gives one experience you can’t gather even from all these other sources,” she adds.

Zeilman agrees that training is critical. “This population has traditionally been provided service by social workers, so LPCs (licensed professional counselors) seem to be newer to this population,” she says. “My formal educational training as an LPC provided an excellent foundation, but it was absolutely necessary to seek professional training outside of my formal educational training to increase my competence.”

Working with foster children and adopted children offers counselors unique opportunities to witness and learn from the resilience that these children demonstrate, Zeilman says. She recalls working with one child who had been physically and emotionally abused by family members before being placed in a wonderful foster family. After seven months of therapy, the girl no longer needed any psychotropic medications.

“Her birth father had filed an appeal to the Termination of Parental Rights ruling,” Zeilman says. “This client had moved forward so much by the time court arrived that she asked to address her birth father, expressing that she loved him, that he would always be her father, but that she wouldn’t accept his behavior. She asked him to let her go — all unscripted and unprompted. This was a child who was still in elementary school. As much as we work to help our clients, we often forget how much we can also learn from them. I learned much from her strength, her courage and her ability to remain hopeful.”



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