Thomas moved on and off between his birthmother and paternal aunt for the first seven years of his life. He was removed from that unstable situation after his aunt threw him down a flight of stairs, breaking his leg.

Now 10, Thomas has been in his pre-adoptive home for one year. As finalization nears, Thomas seems to be changing from a child who was eager to please, to one who is contradictory and noncompliant. He ignores many of his parents' directives and becomes anxious when reprimanded in any way. In addition, his school work is suffering, a turn of events that is particularly upsetting to his parents. His parents are wondering.. Who is this child?

Many of the stories of children who enter the foster care system involve abuse - physical, sexual or emotional - neglect or abandonment. Care giving adults may be drug or alcohol addicted or mentally ill, unable to care for themselves, let alone children. In some instances, children have witnessed violence, even murder against loved ones. A large proportion of children lose connections with birth family members; others remain in contact with family members with whom they have ambivalent, conflicted and difficult relationships. For some children, placement occurs because a caregiver has died. Unfortunately, multiple caregivers and moves both prior to and subsequent to placement in foster care compound the experience of trauma and loss.

Amazingly, adults often expect children to move into adoptive placements smoothly, settling into their new lives with relief and minimal disruption. It is hoped that children can understand how the old and the new are separate worlds, and despite the considerable efforts of many people, those two worlds are permanently apart. These expectations, combined with the fact that adoptive parents may have had little knowledge of how prior trauma can cause depression, anxiety or acting out behavior, may be a recipe for disaster.

Fortunately, much has been learned about the long-term impact of trauma on both children and adults. However, not all foster and adoptive parents are informed, and some mental health practitioners are unaware of the powerful, unique complexities of loss for children in foster care and adoption. It is critical that social workers learn how unresolved grief about previous losses can manifest itself in new home environments, and that information must be shared. Fears and worries grounded in former experiences must be recognized and addressed to diminish difficult or puzzling behaviors that challenge new families where safety and nurturing are present.

Last year, Tomas was referred to The Center for Adoption Support and Education, Inc., or C.A.S.E., in Silver Spring, MD, with his foster soon-to-be adoptive parents. Their therapist, Madeleine Krebs was not surprised by the route that Thomas had taken to reflect his anxiety and insecurity. She began by asking Thomas, "How did you get to this family?" She created a trusting relationship and a safe place where he could share his understanding of what had happened in his life and process his feelings related to his experiences and the losses he incurred.

Over time, through the use of activities designed to help him express his sadness and confusion, Thomas shared his anger. He made balls out of clay and threw them at the couch in Krebs' office, expressing fury at his aunt who had hurt him. Sometimes he would get angry at Ms. Krebs, who used the opportunity to help Thomas see that it was all right for him to get angry - healing his sense of trust in adults. He talked about his concern about the fate of a cat that had lived with him at his birthmother's home, eventually letting Ms. Krebs know that he was worried about his birthmother and wondered where she was.

Ms. Krebs also worked with Thomas' parents, coaching them to provide Thomas with what he needed, as well as how to respond appropriately to his difficult behavior. Ms. Krebs notes, "I needed to help his parents understand how his traumatic past resulted in a lack of trust which translated into anxiety, insecurity and a hyper-vigilant stance in the world."

Thomas was testing his parents, and needed reassurance that he would be accepted and loved despite his misbehavior. In addition, Ms. Krebs helped Thomas' parents understand how his emotional challenges may have been interfering with his ability to learn and that throughout time, this might improve as well. In the meantime, she emphasized the importance of providing Thomas with support. The C.A.S.E. model of therapeutic support incorporates understanding of the impact of trauma, grief and loss in foster care and adoption as it relates to attachment. The concept of ambiguous loss, as described by Pauline Boss in Ambiguous Loss: Learning to Live with Unresolved Grief, and the good grief model developed by Maria Trozzi in Talking with Children about Loss, are important theories for treating children who continue to have contact with birth parents, as well as those who do not.

Ambiguous loss refers to loss which is uncertain and often unrecognized by others because it does not follow traditional patterns leading to closure. Unlike the finality of death, for example, ambiguous loss blocks the coping and grieving process because the loss situation may change. Children may believe they will reunite with birth families. Without more absolutes, the "family relationship freezes in place," Boss states in her book, complicating children's ability to move on and form new attachments, despite their need to do so.

The "good grief" model outlines the stages of grief for children and teens, and emphasizes that "grief shared is grief diminished," as stated in Boss' book. Trozzi believes that grief cannot be rushed, and that children need to be in trusting relationships to work through the pain of their losses.

The first of the four stages identified by Trozzi is understanding. At C.A.S.E., therapists help children to verbalize their perception of the situation that caused the loss. Sometimes information can be added or corrected, or different perspectives can be provided to help children comprehend why events occurred. Sometimes loss is not of a person, but of innocence, trust or safety.

Lifebooks are helpful tools for concretizing the past for children. At C.A.S.E., therapists also help children identify "lifelines" that provided support to them at critical points in their young lives. Lifelines are clues for effective coping skills that can be useful again. They may be people, or activities such as playing sports, reading, phoning a friend, or they may simply be thoughts that were comforting or encouraging at a difficult time.

The second phase is grieving. Ms. Krebs notes that children can be helped to understand that painful feelings are normal, they can be expressed in healthy ways, and that they do not go on forever. "We need to help them keep faith and hope for the future."

The third phase, commemorating, helps children believe that there is value to their loss and that others will acknowledge the loss. Ms. Krebs emphasizes the importance of helping children keep and treasure photos of people and places. In addition, foster parents can maintain respect for children's losses through language. An example, "I was thinking about your birthfather today, and I wonder if he had a good throwing arm when he was young . just like you!" Or, "I know your sister's birthday is this month. Would you like to make a card that we can send to her?"

Finally, the fourth phase is, going on, or moving forward with life by accepting and integrating the loss psychologically and emotionally within. However, children are likely to move back and forth through these phases; it is not unusual for them to return to intense grief when it has appeared previously that their sadness had waned.

The nature of loss for children in foster care is deep and often affects their self-worth. Many lose not only their birth families but possibly friends, teachers and pets. Often they have moved form school to school and are unable to keep mementos or schoolwork that made them proud. They may lose things along the way, such as clothing, books and photos. Grieving these losses is no quick or easy task.

The importance of grief work cannot be overstated. When children are not given the opportunity and assistance to effectively communicate their grief as well as the feelings related to other traumatic experiences, the result can be a serious erosion of self-trust as well as trust in others. The result can be feelings of incompetence, and a belief that the world is unfair, unsafe, and unmanageable. These powerful emotions, if not recognized and alleviated, can have a serious negative impact on a child's ability to attach to a new caregiver.

Shana, 15, was removed form her biological family at age 10 after her mother failed to retrieve her and her 8-year-old brother from a babysitter's home. After living in several foster homes, she was placed for adoption at age 11. She entered therapy four years after adoption because she felt unattached to her adoptive parents and was asking to be removed from their home. Shana's parents had reached the point where they wondered, "She is so insistent about this, is there nothing we can do but let her go?"

Treating traumatized teens can be especially challenging because, according to Debbie Riley, Executive Director of C.A.S.E., teens frequently deny that they need the help of a therapist and that problems exist. Instead, teens may present self-injurious behaviors, depression, anxiety, anger-management issues, substance abuse, and relationship problems that stem from previous trauma. She notes that frequently, the situation is complicated because little information is available about the trauma the teen may have experienced in his or her early life. To heal, the essential components for recovery include the emotional support of the family as well as the therapeutic relationship. The adopted teen may have lived in environments where adults harmed and betrayed him or her, but helping build safe connections with others so that he or she may successfully attach to adoptive parents is crucial.

Ms. Riley describes the process of helping Shana share her story and express her emotions to be complicated. Although Shana tried to push her away, Ms. Riley remained steadfast and worked to slowly build the trusting relationship which helped her describe the sexual abuse she suffered at the hands of her stepfather. Ms. Riley sat with Shana as she poured out her pain, rage and fear that she was unlovable. The experience of sharing her memories led to Shana's ability to recognize and grieve the loss of the friend and other people she missed from her previous life.

Ms. Riley's work with Shana's parents centered on helping them understand Shana's traumatic past and the impact of the past on her ability to trust and attach to adults. Her parents had been unaware of the extent of Shana's experiences. Her rejection of her parents was an attempt to protect herself from future harm. Shana's parents were warm, loving people who did not want to lose her but had been hurt themselves by her behavior. They agreed to "hang in there with her" as long as she agreed to continue with them and her therapy.

"How kids work through the mourning process and grow from it is up to us," Trozzi notes. Children who are separated from birth parents and those who have been involved with the foster care system have experienced disruptions and losses that affect their ability to adapt to a family environment. It is up to adults - parents, social workers, nurses, doctors, and teachers - to anticipate, accommodate and support these children as they grieve. Many children cannot maneuver through the complexities of their significant losses and their life stories without support that is enhanced by deep appreciation for the unique nature and challenge of those losses.

© 2004 The Center for Adoption and Support Education, Inc.

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