Trauma-informed Interventions in Relative Adoptions of Older Children: Improving Outcomes (originally written on 8/15/21)

Abstract

This paper set out to discover the extent of trauma in older children adopted into relative adoptions and ask, do the traumas experienced by older children adopted in relative adoptions warrant the same consideration in mental health care as those of foster children? Some scholarly research on the trauma experienced by foster care was available and a small amount of research that included kinship care did exist. Many themes were found in the available research; those themes were adverse childhood experiences, complex trauma, and attachment disorders. The available research points to these themes causing life-long issues for these children. Some of the research does point to these same themes being just as prevalent in older children in relative adoptions. While this research was limited to secondary research the author does discuss possible future research to further solidify the answer to the question at hand. This paper concludes that even though there is limited data on the trauma experienced by children adopted into relative adoptions at an older age, the evidence that is available shows that at least some of these kids experience comparable complex trauma as those in foster care. Possible solutions and changes in support programs, that could improve outcomes for these kids, are discussed.

Trauma-informed Interventions in Relative Adoptions of Older Children:

Improving Outcomes

Five years ago my spouse and I brought our 10 year old nephew into our home. We were at least his 5th home, and the 3rd since he was removed from his mother by the court. We had no idea the trauma that he had experienced and how that would affect all of us going forward. Now, after having adopted Aiden as our son, we are finding that the acute, situation based, short term psychotherapy available to us through our insurance is inadequate or non-existent. The goal of this paper is to show that our son, and others like him, are in need of trauma-informed attachment based care.?

There is a lot of research into trauma-informed care and attachment therapy for children who have come out of the foster care system (Miranda et al., 2019; Purvis et al., 2015). Before placement in permanent homes foster care children experience Adverse Childhood Events (ACEs) including all types of abuse, household dysfunction, and neglect (Paine et al., 2020).? These repeat ACEs result in complex trauma as defined by Van der Kolk (2005): “multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature… and early-life onset” (p. 402). These interpersonal traumatic events, or relational traumas, cause issues in the child's ability to form secure attachments (Fagan, 2011). There is limited research on the same ACEs in older adopted children who were never part of the foster care system. These children may have gone through a relative adoption or similar rehoming. This body of research will look at the children who fall into this gap of kids who were not in the foster care system, but have been rehomed at an older age. I hope to show that these kids not only experience complex trauma and insecure attachment but would benefit from trauma-informed attachment focused psychotherapy. My research question is: do the traumas experienced by older children adopted in relative adoptions warrant the same consideration in mental health care as those of foster children?

Review of the Literature

My research started with looking on EBSCOhost and other scholarly databases for research into the trauma of adoption. Keyword terms “adoption”, “trauma”, “trauma informed”, “attachment disorder”, “relative adoption”, “kinship care”, “older adoption”, and related terms were used to find sources. A lot of the existing research that did deal with adoptions and trauma were focused only on foster or institutional adoptions not relative adoptions. What became clear was that research dealing directly with relative adoption and complex trauma or insecure attachment is scarce.?

Trauma:

ACEs and complex traumas:?

Van der Kolk’s 2005 work is a close up look at the concept of Developmental Trauma Disorder (DTD). Van der Kolk makes the argument that even though children typically don’t qualify for the diagnosis of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders they still exhibit the symptoms due to complex trauma; these complex traumas come from repeated ACEs and result in DTD. Van der Kolk concluded that unless and until these children are given the tools needed to develop new ways of dealing with previous traumas, they are doomed to repeat them.

In 2016 by Hartinger-Saunders et al. grouped adopted kids and foster children together. The work presented by Hartinger-Saunders et al., (2016) looked at the needs of children adopted from foster care. They proposed that society needs to offer more pre and post adoption services to adopted kids and their adoptive families in order to create more permanence. Hartinger-Saunders et al., (2016) found that kids who were experiencing multiple ACEs showed long-term behavior problems. Hartinger-Saunders et al. discovered trauma-informed treatment methods that were beneficial to kids with complex traumas, or DTD; however, they also discovered that most adoption services have limited post-adoption services that have arbitrary time limits.? This conclusion is in line with the van der Kolk (2005) perspective on DTD and it’s deleterious effect; showing the need for this type of specialized care to be available.

Using questionnaires Paine et al. (2020) performed a longitudinal study into the specific effects of pre-adoptive risk factors on the children’s emotion and behavioral problems. They looked at children in kinship and foster care over the course of 4 years after adoptive placement. They used child adoption records (CAR) mandated in the UK for all children with an adoption plan, along with questionnaires that adoptive parents filled out. They used multiple models to validate their results. The author’s findings built upon other previous research. Paine et al. (2020) concluded that children adopted from out of home care are prone to mental health issues and there are direct correlations between early adversity and outcomes later in life. This research supports the earlier findings of van der Kolk (2005) and Hartinger-Saunders et al. (2016) that pre-adoptive risk factors like multiple ACEs and complex trauma affect the future mental health of these children.

Attachment disorders after trauma:

The research by Miranda et al., (2019) dived into the experience of being in foster care and how it related to attachment styles to discover a connection between foster care and attachment styles. In-depth interviews were conducted by Miranda et al. to gain insight into the foster care experience. They concluded that foster care in itself frequently results in insecure attachments; further, it was overall a negative and traumatic experience.?

Late adoptions and attachment:

Fagan (2011) did research into attachment disorders as they relate to relational traumas and late adoption using the treatment of two children; children with clear relational traumas and attachment disorders. The long term consequences of these traumas are explored in depth using his treatment notes. The author attempts to connect psychoanalytic thinking and research into child development to better psychotherapy outcomes for similar children. The paper (Fagan 2011) showed how kids who were adopted late live in two worlds, the new and the old, and struggle to keep them straight. This duality can cause stress on the child and the adoptive family. Again we find alignment in our data; this research is in line with Miranda et al. (2019) and the work mentioned earlier by Paine et al. (2020), van der Kolk (2005) and Hartinger-Saunders et al. (2016).

Outcomes:?

Foster care vs. kinship care

A study by Bell & Romano (2017) looked at the differences in outcome between kinship care and foster care; it provided some interesting insights. They reviewed available quantitative research on kids in out-of-home care from 2007 to 2014 to find data on permanency and safety. In their paper Bell & Romano (2017) concluded that kinship or relative care resulted in more permanency compared to foster care, yet fell behind in adoption and reunification rates.

Trauma-informed help:

In their 2015 research Purvis and colleagues looked into the effectiveness of trauma-informed interventions on behavioral issues in adopted children, specifically children adopted from institutions both foreign and domestic. This is a randomized study; the methods used were thorough and tried to account for all bias and variabilities. Purvis et al. (2015) used well established reporting tools such as the Strengths and Difficulties Questionnaire (SDQ) and the Trauma Symptoms Checklist for Young Children (TSCYC) both pre and post intervention. The intervention consisted of an intensive 4 day training for the parents in trust-based relational intervention (TBRI). The results from Purvis et al. (2015) shows that over time there was a reduction in behavioral concerns and an increase in prosocial behavior after parental training. Purvis et al. make the case that TBRI interventions are important to the child-caregiver relationship which in turn affects the behavioral outcomes (p. 206).

Ko et al. (2008) looked at the ways that child support systems can work together to implement trauma-informed solutions. The authors propose 7 recommendations to be implemented by the five different support systems discussed in the article: child welfare, education, first responders, healthcare, and juvenile justice; Ko et al. (2008) concluded that these changes will benefit outcomes for traumatized kids.?

Methodology

I enjoyed doing the research for this project, maybe too much considering the amount of pdfs I have in my downloads folder. I used EBSCOhost and UW library resources to access and find scholarly journal articles using terms such as “adoption”, “trauma informed care”, “attachment therapy”, and “foster care”. Most of that research however, missed the mark on my research question. It was useful to see what research had been done and what they found. The tangential research was able to give me a basis to build my plan for primary research as seen in the Appendix.

Limitations:

This researcher was limited in his ability to conduct the desired research. The time available was insufficient to find appropriate subjects that fit the profile of relative adoptions of older children. All of this during covid, making face-to-face interviews almost impossible. I hope to finish this research as outlined in the Appendix. In the meantime, I hope this secondary research can provide some starting point for future research.

Discussion

As is evidenced by the literature review there is a gap in the research into the traumas of older relative adoptions. I have presented good existing research into the effects of those ACEs and complex traumas on the development, behavior, and long term outcomes of children adopted at an older age. I’ve shown the connections in the literature between ACEs, complex trauma, and attachment disorders. How does this relate to older children in a relative adoption? The lack of research into this group of adopted children is allowing them to slip through the cracks and must be resolved.

ACEs, complex trauma, and attachment disorders:

Van der Kolk (2005) with their Developmental Trauma Disorder (DTD), and Paine et al. (2020) who researched the negative impact of ACEs, show us the dramatic effects that ACEs and complex traumas have on children. Miranda et al. (2019) performed research into the effects that complex trauma has on attachment models. It is clear from the research that children who have experienced ACEs and complex trauma go on to have negative long term effects. These ACEs seem to also have a dramatic effect on the child’s ability to form secure attachments.?

Trauma in Foster and Kinship Care:

In their 2019 article Miranda et al. give us a view into the attachment disorders resulting from the complex trauma of foster care. Some themes emerged from the interviews in Miranda et al. (2019); themes emerged of insecure attachment styles, attachment injuries, and systemic issues. Common among the subjects were trust issues, anxieties, relational styles, traumas, stolen childhood, a broken system, and failed counseling. Their results showed ”foster care alumni exhibited problems during childhood but had implications for all adult relationships” (Miranda et al., 2019, p.102). Miranda et al. (2019) reported most foster care alumni felt individual counseling was unhelpful and focused on third party goals other than helping the child with their trauma related issues, thus perpetuating already existent trust and attachment issues. These insecure attachment styles lead to difficulties in forming relationships; left untreated in counseling there can be life-long effects.

New research (Paine et al., 2020) shows a negative impact of multiple ACEs on a child’s mental health coping scores over time, resulting in mental health issues as adults. Children in care are, according to Paine et al., more likely to have an increased number of ACEs, causing externalizing and internalizing problems. They found these problems are more likely to continue after adoptive placement for children in foster care. This paper did not distinguish between children in foster care as we know it in the United States and kinship care which is commonly part of their child welfare system in the UK demonstrating that children in kinship care are in need of early and continual intervention and care to deal with accumulated ACEs.

Effects on older adopted children:

The effects felt by older children seem to be even more dramatic. In-depth research (Fagan, 2011) into the experiences and treatment of two traumatized children shows us that older children live in two worlds, the old and the new. Fagan wrote about the struggle the kids go through with a “sudden substitution of one reality with another, with a ‘falling back’ to a previous way of relating” (Fagan, 2011, p 140). This feeling is not limited to just these two kids; it was a result of their traumatic past experiences with neglect and abandonment, things common to many adopted children. This unique experience of the older adopted children combined with multiple ACEs leads to more insecure attachments and negative outcomes, compounding the issues already faced by being adopted in foster of kinship care.

Changing outcomes:

Ko et al. (2008) spells out changes healthcare providers can make to help traumatized kids. They need to be aware of children and families dealing with trauma and incorporate that in their interactions, and work to reduce trauma in medical care. They can also help spot signs of trauma in the family. Mental health care workers can integrate more trauma informed practices and treatments into their work. The authors (Ko et al., 2008) do recognize that not all recommendations are appropriate for all practitioners but suggest integrating in their research what is appropriate across the groups discussed. Making these simple changes in the way services interact with traumatized kids can be a game changer in their long-term success.

Purvis and colleagues (2015) have shown positive results of Trust-Based Relational Intervention (TBRI) training for adoptive parents. Their work was able to show a reduction in emotional and conduct problems, hyperactivity, and total difficulties while increasing prosocial behavior after parental TBRI training, as seen in Figure 1; in contrast the control group showed an increase in all metrics with a smaller increase in prosocial behaviors in comparison. The connection the caregiver builds with the adopted child through the TBRI techniques mitigates trauma effects and builds attachment (Purvis et al., 2015). They concluded that using the caregiver as the force for change resulted in positive results for the child that lasted longer into the child's adult life. Providing proper training to parents of adopted children gives them the tools they need to help their kids and know when to seek professional help. TBRI techniques can be quickly learned and utilized effectively with great results (Purvis et al., 2015).

Note. Data from Purvis, K. B., Razuri, E. B., Howard, A. R. H., Call, C. D., DeLuna, J. H., Hall, J. S., & Cross, D. R. (2015). Decrease in behavioral problems and trauma symptoms among at-risk adopted children following trauma-informed parent training intervention. Journal of Child & Adolescent Trauma, 8(3), 201–210. https://doi.org/10.1007/s40653-015-0055-y

Conclusion:

Research presented in this paper shows that ACEs, complex trauma, and attachment disorders are present in children adopted from foster care and from kinship care (Paine et al., 2020; Miranda et al., 2019; van der Kolk, 2005; Hartinger-Saunders et al., 2016). The similarities in ACE types and numbers of these two groups is evident. Fagan (2011) closes the gap and shows how these ACEs build into complex trauma and then cause attachment disorders.The attachment disorders that come as a result of the complex repeated relational traumas are not diminished simply because it is kinship care and not strangers, even though this seems to be the prevailing view of modern healthcare. In the child’s experience, the trauma is the same and the need for specialized trauma-informed care is clear. We see that children adopted when they are older live in two separate worlds, ones they can’t always keep straight. These two worlds are often in conflict and leave the child confused. They need professional help to develop the tools needed to grow and make sense of their story. Note, tools for coping along with secure attachment styles are the solution; as van der Kolk states “Unfortunately, all too often, medications take the place of helping children acquire the skills necessary to deal with and master their uncomfortable physical sensations” (van der Kolk, 2005, p. 408). We need to encourage the healthcare system to make more trauma-informed choices in the way they offer care, not just offer a pill or another short-term fix. Finally, I conclude that the best thing society can do to help adoptive parents, adopted kids, and the future relationships of these children is provide training like TBRI to parents adopting kids from both foster and kinship care. Trained parents can provide that safe, secure, launching pad that these kids so desperately need to develop the tools to be happy healthy members of their community. The research clearly shows that in order to improve the outcomes for these children and their families we must begin to recognize the need for and implement Trauma Informed interventions like attachment focused psychotherapy, trauma-informed mental health, proper training for adoptive parents such as TBRI, and a systematic review of the way supports systems interact with and support traumatized children. Improving lifelong outcomes for these children will improve life for the kids, life in the community, and the society they are a part of.

Future research:

I propose that research like presented in the Appendix would not only fill the research gap, but finally bring some light and clarity to the issue. This research, done through interviews, would capture the data necessary to bridge the gap. This data could finally show if the hypothesis that relative adoptions, with their higher permanency success rate, is still traumatic and deserves to be taken seriously by healthcare providers. We hope that someday soon this research will be done and we will have the answers we seek.

References

Adverse childhood experiences. (2021, May 26). Wikipedia. https://en.wikipedia.org/w/index.php?title=Adverse_childhood_experiences&oldid=1025176404

Bell, T., & Romano, E. (2017). Permanency and safety among children in foster family and kinship care: A scoping review. Trauma, Violence & Abuse, 18(3), 268–286. https://doi.org/10.1177/1524838015611673

Fagan, M. (2011). Relational trauma and its impact on late-adopted children. Journal of Child Psychotherapy, 37(2), 129–146. https://doi.org/10.1080/0075417x.2011.581467

Hartinger-Saunders, R. M., Jones, A. S., & Rittner, B. (2016). Improving access to trauma-informed adoption services: Applying a developmental trauma framework. Journal of Child & Adolescent Trauma, 12(1), 119–130. https://doi.org/10.1007/s40653-016-0104-1

Ko, S. J., Ford, J. D., Kassam-Adams, N., Berkowitz, S. J., Wilson, C., Wong, M., Brymer, M. J., & Layne, C. M. (2008). Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice. Professional Psychology: Research and Practice, 39(4), 396–404. https://doi.org/10.1037/0735-7028.39.4.396

Miranda, M., Tadros, E., & Molla, E. (2019). The experience of foster care and long-term attachment. The American Journal of Family Therapy, 48(1), 87–106. https://doi.org/10.1080/01926187.2019.1679053

Paine, A. L., Fahey, K., Anthony, R. E., & Shelton, K. H. (2020). Early adversity predicts adoptees’ enduring emotional and behavioral problems in childhood. European Child & Adolescent Psychiatry, 30(5). https://doi.org/10.1007/s00787-020-01553-0

Purvis, K. B., Razuri, E. B., Howard, A. R. H., Call, C. D., DeLuna, J. H., Hall, J. S., & Cross, D. R. (2015). Decrease in behavioral problems and trauma symptoms among at-risk adopted children following trauma-informed parent training intervention. Journal of Child & Adolescent Trauma, 8(3), 201–210. https://doi.org/10.1007/s40653-015-0055-y

van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401–408. https://doi.org/10.3928/00485713-20050501-06

Appendix

Future Research Proposal

Overview

More research is needed into this issue that affects so many kids in the US and around the world. We need to look at why kinship care rarely ends in adoption and how that affects the child; it behooves us to investigate the ACEs and complex traumas that children in relative adoption experience and the best way to help them. We owe them this, at least.?

Rational:

My study is focused on the gap that I find in the research into ACEs and the effects of the resulting complex trauma on adopted kids who were never in the child welfare system. Because of this narrow research I am conducting interviews with subjects who were placed into a relative or kinship adoption. These types of adoptions are rare so a wide reaching survey is not appropriate; the goal is specific information about the experience not the prevalence. My audience is the mental health industry, specifically the insurance companies; these audiences require quality data and specific examples for long term care outcomes that I can find in interviews. The questions will ask about past traumatic events or ACEs, current feelings about those events, and about treatment they may have received.

Methodology:

Participants:

The participants will be found through online advertising such as facebook and google. This can be done cost effectively in a short span of time. I would like to find 25 participants to interview. Demographic information will be collected to correct for age and racial disparities in experience.

Questions:

1. How old were you when you were placed into a relative adoption?
2. This question allows me to find out where the subject is on the spectrum of ages considered an older adoption. This is used to assess how at-risk they were and compare to other similarly situated adopted kids.
3. How many homes had you been placed in previously?
4. I wanted to find out how these children’s experiences compare in a quantitative way with the existing research into foster children.
5. What were the circumstances that led to your removal brom your birth parents?
6. This question will give some narrative background and context for the situation the child found themselves in.
7. What Adverse Childhood Experiences such as all types of abuse, household dysfunction, abandonment, and neglect did you experience, no matter how small??
8. I am looking to get detailed information of the types, severity, and frequency of ACEs in kids placed into relative adoptions to compare with similar research into other adoption types.
9. What therapy have you received as an adult for these ACEs? What was the outcome?
10. By asking for their experience of therapy in treating their traumas I can find out how effective mental healthcare is for this group of adults. This information can be used to show efficacy of treatment..
11. What type of therapy or counseling were you offered as a child?? For how long? Did it help?
12. Data on the type of therapy they received as a child, the length, and outcome can be used to show how the results of treatment compare to the results of treatment modalities in other adopted kids. This can possibly show the efficacy of treatment for children.
13. How would you say these events have affected your life?
14. Getting a retrospective from the child as an adult gives me more information on how they experienced the ACEs that they did. This is a more subjective question ment to draw a bigger picture.
15. How have you struggled with drug and alcohol abuse?
16. This is data that can be compared to other studies of adopted kids who were in the foster or welfare system, allowing me to triangulate the data.