An Approach to Working with the "Placed Child"
Phillip M. Clifton, MD Jane W. Ransom, MSW, ACSW University o f Virginia Medical C~nter
A B S T R A C T : This paper presents an approach to working with the diagnostic and therapeutic challenges posed by the "placed child." A thorough knowledge of child development, combined with awareness of the basic tenets of crisis intervention, offers the child mental health professional guidelines to assist placed children in coping with their uncertain environment. Parents and agencies are guided toward stabilizing the child's environment, while the child is maintained in play therapy to assist him in coping with the confused and frightening emotions that attend the experience of placement separation. Three clinical cases are presented that illustrate an active short-term therapy, a form of primary prevention attempting to forestall the potential damage of unresolved placement separation crises.
Child mental health professionals are familiar with the often difficult separations and adjustments children experience when they are placed in institutions, taken into foster and adoptive homes, or caught up in custody battles that result from marital separation and divorce. These children make up a substantial proportion of clinic populations. The importance of stable and consistent parenting to a child's development is well substantiated in the literature. Margaret Mahler [ 1], in formating infantile psychosis, studied the normal development of the mother-child relationship. She concluded that a need-satisfying mother-infant relationship during the 1st year of life is essential for normal development. The infantile and early childhood suffering resulting from mother-child separations in such distressing circumstances as maternal death or serious illness of mother or child has been studied by John Bowlby [2, 3, 4], and the difficult adjustments of children separated from their families during wartime have been reported by Anna Freud and Dorothy Burlingham [ 5]. Dr. Clifton is a Resident in Child Psychiatry, Division of Child and Adolescent Psychiatry, University of Virginia Medical Center, Charlottesville, Virginia 22901. Child Psychiatry and Human Development
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The environment in which a child develops is a variable of crucial significance in formulating any therapeutic approach for children. But what is the role of child mental health professionals in helping the placed child to reach his or her full potential and to avoid the neurotic or sociopathic aftermath of multiple placements and general environmental confusion? This paper will present a therapeutic approach to working with the placed child posited on the child mental health professional's responding to a child's needs in the midst of crisis. Howard Parad [6: p. 197] delineates the components of crisis as: (a) an identifiable stressful event; (b) the individual's perception of the event as threatening to "such vital goals as life, security, and affectional ties"; (c) a disorganization and disequilibrium response; and (d) the coping and intervenrive tasks involved in resolving the crisis. Considering the stressful event to be a child's actual or threatened separation from parent figures, the therapeutic approach presented involves the need for sensitive awareness of h o w the child perceives this separation and his uncertain environment. One important aspect of this approach is an awareness of the child's emotional and cognitive development. Joseph Goldstein, Anna Freud, and Albert Solnit [7] argue very effectively in their recent publication, Beyond the Best Interests of the Child, that our present legal system is less than fully cognizant of the child's developmental needs and his singular way of responding to his environment, differing from that of adults. These authors point o u t that the y o u n g child sees no merit to the claims of blood relationship, but instead develops emotional ties to those who fulfill his daily needs for physical and emotional nurturance. The passage of time, for the y o u n g child, is experienced according to the "urgency of [his] instinctual and emotional needs" [7: p. 11] with extreme reaction to lengthy separations and unfulfilled needs. Ner Littner [8], consultant psychiatrist for the Illinois Children's Home and Aid Society, in 1956 studied the traumdtic effects upon a child of separation and placement. He describes the child's experience of abandonment, encompassing feelings of loss, humiliation, and worthlessness. He speaks of the child's a t t e m p t to handle his anger and his total helplessness by holding himself, and some specific wickedness, responsible for the separation. For his anger and wickedness the child fears and expects retaliation, often seeing his new parents as the instrument of his punishment. Once some initial adaptation to his placement has been achieved, the child, according to Littner, must further cope with his dangerous wish to love his new parents, and his
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fear that he will be rejected by them. Littner emphasizes the importance of the child care professional's being adept at identifying the feelings a child experiences in placement. He comments, "I would like to remind y o u of one of the greatest difficulties that we experience in the placement of a child--namely, our problems a b o u t seeing things through his eyes, and of adequately understanding and being sensitive to the real meaning of what he is trying to tell us, through his verbal and non-verbal behavior" [8:p. 31]. It would appear that the child experiencing placement separations is likely indeed to define these events as threatening to his life, security, and affectional ties. The s y m p t o m s that bring the placed child to professional attention represent the "disequilibrium response" of an individual in a crisis state. The recently developed crisis literature gives therapeutic guidelines that can be used to assist the child and his family in accomplishing the necessary coping tasks. In discussing the concept of "primary prevention," Gerald Caplan [9: p. 26] speaks of lowering the incidence of mental disorder by "counteracting harmful circumstances before they produce illness." Littner [8: p. 20] refers to two factors that affect the a m o u n t of personality damage resulting from placement separations: the child's age at separation, and the extent to which he represses his painful feelings. It is vital to the y o u n g child's emotional development that he be helped to deal with his placement experience in such a way that he achieves an adaptive resolution of this crisis. Caplan [9: p. 41] describes the crisis state as involving "the emergence of old problems accompanied by a significant emotional reaction," indicating that the problems "were not satisfactorily dealt with in the past." Erich Lindemann's [10] classic study of grieving patients {including those bereaved by the 1943 Coconut Grove nightclub fire in Boston) discovered in his sample some patients whose severe reaction to the recent loss signified an unresolved grief reaction from many years ago. In helping bereaved patients to accomplish their normal "grief w o r k " and to achieve a healthy readjustment, Lindemann and his colleagues established the p r o t o t y p e of "preventive" crisis intervention. In the idiom of Caplan's Principles of Preventive Psychiatry, the placed child is at special risk and in need of preventive attention lest the unresolved crisis of his placement separations be the cornerstone for later disturbed functioning. The crisis-oriented approach offers a format for clinical intervention with the placed child and his family that should help to achieve an adaptive resolution of the crisis of separation. First, there is an ac-
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c e p t a n c e o f explicit, time-limited goals, highly i m p o r t a n t to the child w h o s e need for security a n d e m o t i o n a l gratification is pressing. Seco n d , the therapist assumes an active role, using his p s y c h o l o g i c a l and p s y c h o a n a l y t i c b a c k g r o u n d t o assess the situation, t o e n c o u r a g e o p e n expression o f feelings related t o the crisis, and t o m o v e into direct int e r p r e t a t i o n a n d o p e n c o n f r o n t a t i o n , as a p p r o p r i a t e , with the child and his family. Third, the t h e r a p i s t utilizes such specific crisis-dealing t e c h n i q u e s as direct advice and e n v i r o n m e n t a l m a n i p u l a t i o n . Case R e p o r t s
Case 1 Betty, 6 years old, was referred for psychiatric evaluation by her adoptive parents, Mr. and Mrs. G., because Betty "didn't seem to be fitting into the family." When Betty's adoptive parents were seen together for an initial evaluation interview, they presented the problem as being one of "Betty's not sure she wants to be our little girl." Three months prior to the G.'s presentation for evaluation, 10year-old Gregory, 9-year-old Johnny, and 6-year-old Betty had been placed for adoption in the G.'s home. The adoption of the three siblings had not been finalized at the time of referral. Mr. and Mrs. G., a childless couple in their early 30s, had decided to adopt children approximately 2 years prior to being seen at this clinic. Mr. G., an engineer, and Mrs. G., a medical technologist, had cared for a number of foster children successfully in their home, and they felt they were ready to have a permanent family. The three children were abandoned by their biologic mother 5 years previously and had been in group foster placement prior to their trial adoptive placement with the G.'s. Past history. Six-year-old Betty remembered no family other than her foster parents. The foster father died when Betty was 3 years old, so that her only longterm parental relationship was that with the foster mother. This foster mother is described in a social study by the local welfare agency as being obviously partial to Betty over the other foster children in her home. Betty slept with the foster mother after the foster father's death, and was often found sitting in the foster mother's lap when the social workers visted the home. Adoption was sought for Betty and her brothers because the foster mother was in her mid-60s, with health problems that compromised her ability to care for the children in her home. Betty experienced more difficulty in making the separation from her foster mother than her older male siblings. In the initial 3 to 4 weeks with Mr. and Mrs. G., Betty was enuretic, had nightmares, and was noted by Mr. and Mrs. G. to be shy around other children and not as outgoing as her brothers. The G.'s were aware of Betty's preferential treatment in her previous foster placement, and they felt that this accounted for some of her difficulty in making the adjustment in their home. However, when Betty began, in the 2nd month of her placement with the G.'s, to express a desire to go back to the foster mother the G.'s were shaken, and in their initial interview with the therapist Mr. G. said, "We don't want to make Betty live with us if she doesn't want to be in our home." The G.'s questioned if they should proceed to finalize the adoption for Betty. They had
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discussed with Betty the possiblity of her leaving their home and her two brothers remaining with the G.'s. T r e a t m e n t a n d clinical course. When Betty was seen for evaluation, she presented a pleasant physical appearance, with long blonde hair and an angelic face. However, in the playroom she was inhibited and seemed frozen by anxiety. She remained in one chair throughout her initial interview, never venturing out to examine any of the playroom material. She was most spontaneous when she talked of two cats she had at Granny's house and how she missed them. After the initial interviews with Betty and her parents, it seemed crucial to formulate a therapeutic approach that would help both Betty and her adoptive parents deal with the immediate adjustment problems. The G.'s were anxious about falling in their new role as parents, and they saw Betty's continued talk about her foster mother as evidence of their failure to parent adequately. They were inappropriately allowing Betty to make the decision of whether to go or stay, which only heightened the girl's anxiety. Betty's anxiety, manifested by wetting, nightmares, and tenseness, was an indication of the repressed feelings regarding her separation from her overprotective foster mother and placement with her new adoptive parents. Contrary to what Betty's adoptive parents thought, her difficulty in accepting them had little to do with their ability to parent. Betty feared closeness to new parenting figures. For Betty, loyalty to new parents implied disloyalty to old, and the fear of being rejected again kept her from becoming emotionally close to the G.'s. An interpretive interview was held with the adoptive parents, and they agreed on a 2-month period of crisis-oriented work that would include weekly play therapy sessions with Betty and biweekly parental counseling with the G.'s. The therapeutic goals were: (a) play therapy for Betty with the goal of allowing her to express repressed feelings about separation from her "Granny" and also to allow the therapist to monitor Betty's emotional adjustment to her new environment; and (b) counseling of adoptive parents--to help them deal with their feelings of inadequacy and to help them better understand the meaning of Betty's behavior as she attempted to adjust to her new home. During the course of eight sessions in the playroom, Betty changed markedly. She gradually became more animated in her play. During the earlier sessions she had two mothers in her dollhouse, reflecting her ambivalence regarding giving up her foster mother and accepting her new adoptive mother. However, as the sessions progressed, Betty began to give evidence that she was accepting her new parents. She played out more sequences involving "mommy and daddy" and on her last play session drew a picture of her new family for the therapist. The adoptive parents used their family therapy sessions effectively. They were open in discussing their frustations in not being totally accepted by Betty, and they were able to accept the therapist's assisting them in understanding Betty's behavior, and not allowing their frustrations to bring about withdrawal, rejection, or retaliation against Betty. The parents did become more relaxed and during the course of counseling sessions proceeded with finalizing adoption of all three children. Approximately 1 year after their initial contact for evaluation of Betty, the G.'s recontacted the therapist. They had moved from the local area and reported that in the adjustment to a new living situation Betty again had occasional enuresis and withdrawal from the family. They asked for recommendations on handling these problems. In the most recent contact, the G.'s had accepted Betty as
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part of their family. The questions they asked reflected their concerns about their daughter's development. They were more confident and less threatened by possible failure as parents.
Case 2 Five-year-old Rosalind was referred for evaluation by a public health nurse in response to her stepmother's request. Rosalind's presenting symptoms were "lying, wetting her pants, and breaking toys." Past history. Rosalind is the youngest child born to her biologic parents, whose stormy marriage ended in their separation when Rosalind was 15 months old. Together with her mother and her two brothers, Rosalind joined the maternal grandparents' home. Two years later her brothers' custody was transferred to their father and his new wife, but Rosalind's fate remained unsettled as she shifted about from grandparents to mother to father, depending on her mother's ability and desire to care for her. At the time of referral she had lived continuously with her father and stepmother for about a year, but during each visit her mother promised Rosalind, " I ' m going to take you just as soon as I can get things together." From Rosalind's point of view, chaos reigned in both the families that accorded her a precarious position in their midst. A few weeks prior to referral, during a visit with their mother, Rosalind and her brothers witnessed a violent scene between their mother and her third husband, which resulted in the children's precipitous return to their father's home. At the same time, Rosalind's stepmother struggled with a crisis of her own. The birth of a child to Rosalind's biologic mother triggered in the stepmother unresolved feelings of grief and jealousy from her own miscarriage several months before. This, together with Rosalind's seeming rejection of her as a mother, served to mobilize all her feelings of maternal failure and personal worthlessness. The result was Rosalind's realistic perception of an angry stepmother who, at any moment, might eject her from the family. Treatment and clinical course. Rosalind's intermittent episodes of regressed behavior were seen as reactive to her confused environmental setting, and to the threat this situation represented to her security and affectional needs. The goals established to deal with Rosalind's "disequilibrium response" were: (a) to encourage her three parents to effect a stabilization of her environment; (b) to help her stepmother resolve some of her own anger and grief, and develop a less conflicted relationship with Rosalind; and (c) to enable Rosalind, during the course of play therapy, to cope with the confusion, anger, and apprehension that beset a child in so chaotic a world. The first goal, the vital necessity of settling the issue of Rosalind's custody, was shared in separate interviews with natural mother and with father and stepmother. Each parent was encouraged to express directly his or her ambivalent feelings about Rosalind's future. It developed that her biologic mother, although guilty about relinquishing custody, felt too enmeshed in her own problems to handle any direct commitment to the child. On the other hand, her father and stepmother expressed the desire for Rosalind's custody. They were seen by the therapists as offering her greater strength and security at that time. With open clarification of these issues, and with the therapists' support for settling the cus-
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t o d y matter in favor of father and stepmother, Rosalind's stepmother was able to set in motion the necessary action for transfer o f custody. In accordance with the second goal of helping Rosalind's stepmother to resolve her own feelings and to develop a more positive relationship with Rosalind, crisis intervention therapy was instituted with the stepmother, Mrs. E. She discussed her anger and sadness about her own mother's disapproval o f her recent pregnancy, as well as her extreme grief, heretofore scarcely expressed, at miscarrying this child. She felt sure the lost baby had been a girl "because I wanted a girl so badly," and indicated that a friend had told her "once you have a daughter, you become closer to your own mother." Mrs. E. freely expressed her resentment toward Rosalind's biologic mother, who had been able to deliver a healthy child. Following several months of futile efforts to conceive another child, Mrs. E. became pregnant--about 2 months after Rosalind's referral to the clinic. She experienced considerable fear of another miscarriage in response to relatively minor physical symptoms, but at the completion of her first trimester and her doctor's prognosis of a successful pregnancy, she appeared radiantly in maternity clothes for her next appointment. Rosalind's stepmother discussed at length her wish to be close to Rosalind, and her desire that Rosalind should be "like her," as they were the two "ladies" in the family. She angrily related her hurt at Rosalind's apparent rejection, such as the child's preferring the dresses her mother bought her to those Mrs. E. made for her, and Rosalind's possessive feelings a b o u t her natural mother's new infant. In time, however, her anger toward Rosalind began to subside as she ventilated her disappointment about the child's failure to fulfill the role of her daughter and as she better understood Rosalind's conflicting need for her stepmother and loyalty to her natural mother. Although again heavily invested in delivering a girl, Mrs. E. showed much concern and understanding about Rosalind's reaction should this be the case. She also engaged in some "role rehearsal" of how she would handle Rosalind's feelings and behavior, whether the baby should be a girl or a boy. Rosalind's playroom sessions were directed toward accomplishment of the third goal, enabling her to resolve her confused and angry feelings. In the playroom, Rosalind was preoccupied with domestic scenes--cooking, cleaning, caring for infant dolls. She asked what had happened to the missing baby in the kangaroo's pouch and, with sad affect, related that her " m a m a had a baby that died." Initially, when the therapist a t t e m p t e d to reflect these feelings, she hastily withdrew from the topic. A week after a new brother was born to her natural mother, Rosalind announced, "Our baby has come," and proceeded to display regressed, infantile behavior. Her high-pitched, immature speech and mimicked toddler gait appeared in response to discussion of new babies in her extended family constellation. Rosalind verbalized her confusion about "two mamas and two daddies," sometimes appearing uncertain as to who fitted what title in her array of parental figures. She furiously described her "other mother's husband" who threatened her mother with a knife, and bailing up her fists, said, " I f he ever does it again, I'll get him." She brought a t o y alligator into the playhouse, and guiltily asserted that it would eat up mother, father, and baby. Early in her therapy, Rosalind indicated that if given a choice, she would rather live with her maternal grandmother. As her situation stabilized, she later said that she likes it with "this m a m a " (stepmother) and expressed concern
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about the ill feelings between her two mothers because she "wanted them to be friends." When the custody transfer had been accomplished, Rosalind joyfully announced her new status to the therapist: "I'm going to be staying with my mama and daddy; they told me!" Within a short time, she began to relinquish her regressive behavior and became increasingly tolerant of closeness to her stepmother. She continues to adjust well in school and to experience a warm, caring relationship with her stepmother. She is devoid of symptoms, with the exception of rare wetting episodes felt by her stepmother to be related directly to difficult visits with her biologic mother. The stepmother has shown increasing emotional investment in Rosalind, viewing any behavior problems with compassionate concern and handling them appropriately.
Case 3 Tanya, 5 years old, was brought to the emergency room in her local area during the winter of 1973 by a baby-sitter who was concerned about Tanya's high fever, vomiting, diarrhea, and bruises on her body. Tanya was admitted to the local community hospital and transferred several days later to a university medical center for further inpatient evaluation. The etiology of her fever and gastrointestinal symptoms was found to be shigellosis. She was begun on appropriate antibiotic therapy. Her physical examination also revealed multiple large ecchymoses over the legs, thighs, buttocks, and lower back. Tanya was seen in psychiatric consultation while she was hospitalized on the medical center pediatric ward. Tanya was presenting as a management problem on the ward. She was described as "crying uncontrollably during the evening hours, often waking during the night and found standing in the corner of her bathroom crying and not responding to the reassurance offered by the staff. When first seen, Tanya presented as an average-sized, blonde-haired 5-yearold, found in an infectious disease isolation room on the pediatric ward. She was cooperative and engaging with the interviewer, speaking quite distinctly and answering any direct questions in a pseudomature manner. She talked freely about her stepfather's beating her and attempting to choke her. There was no apparent change in her bright, sunny affect when she described this physical abuse by her stepfather. She became tearful when the interviewer departed the room, pleading for a return visit. The consultant's initial impression after the first interview with Tanya was that her nighttime fears and withdrawal during the evening hours on the pediatric ward were reactive to the abusive home environment she described in the initial interview. Investigations of the home environment were instituted both by the Child Protection Committee of the university medical center and the welfare agency in the girl's local area. Past history. The protective service investigations revealed that Tanya had been the product of an unwanted pregnancy, born to an unmarried mother. Tanya had spent her first years in a rural environment, where her maternal grandmother was her primary caretaker. Because of her grandmother's "bad health," Tanya had come to live with her biologic mother and stepfather for the 8 months prior to her hospitalization. Investigation by the Child Protection Committee resulted in Tanya's custody being given to the local department of social services,
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and Tanya being placed in foster care. Subsequently, the biologic mother relinquished parental rights, making it possible for the local agency to place Tanya for adoption. Initially, Tanya's foster mother found her very difficult to handle. Tanya was described as having fits of uncontrollable anger during the day and screaming resistance at bedtime. Tanya would awaken frequently at night, screaming in terror, often telling the foster mother, "My daddy puts a pillow over my head and I am scared while I am asleep." She also told the foster mother of having to lie down facing her stepfather and being beaten, and if she cried out, turned over on her back and being beaten some more. Tanya never mentioned her mother's physically abusing her. While the foster mother felt great sympathy for Tanya, her behavior was difficult for the family to tolerate. T r e a t m e n t a n d clinical course. One of the first crisis-oriented goals in this case was to help maintain Tanya's foster placement through frequent counseling with the foster mother. Tanya's intolerable behavior was discussed with the foster mother as it related to Tanya's past physical abuse and also to her present emotional trauma of uncertainty in a new environment. In addition to working through past traumatic experiences, Tanya's behavior was interpreted to the foster mother as a means of testing her acceptance in the new foster family. The foster mother was supportively encouraged to be firm with Tanya regarding bedtime, temper tantrums, and aggressive behavior. In addition to work with the foster mother, Tanya was seen in individual play therapy sessions, allowing her to use play as a means of working through some of her immediate separation anxieties and feelings of abandonment and loss. In her initial play sessions, Tanya maintained her bright, happy affect, often singing and busying herself with domestic play, such as cooking and cleaning. However, after the initial session, she began to talk of her stepfather's physical abuse. In contrast to her presentation on the hospital ward, Tanya now had a saddened affect as she talked of the past physical abuse. Tanya also played out sequences regarding her foster mother, whom she would alternately see as sinister and bad, and loving and giving. Tanya obviously wanted to trust her benevolent, understanding foster mother, but she also displaced onto the foster mother the unloving, abusive characteristics she had come to associate with parenting figures. Tanya related well to her male therapist, seeming anxious to please and often coy and flirtatious in her manner. She was described by her foster mother as "all girl," loving to dress up and be pretty. She was noi~iced competing with other children in the foster home for the foster mother's attention. As work with Tanya and her foster mother progressed, Tanya's symptoms improved, and she became integrated into the foster family. The foster mother's impulse to send Tanya to another home was forestalled. Consultation to the local social service agency recommended adoptive placement in the shortest time possible to prevent Tanya and her foster mother from developing a relationship of such depth that Tanya's adoptive placement would constitute another traumatic separation. Fortunately, several appropriate adoptive couples were available, which facilitated Tanya's early placement. The adoptive parents selected were a childless couple in their mid-30s who were "taken with Tanya from the beginning." They visited with Tanya on several weekends before taking her to their home for final placement. The adoptive parents were seen in counseling sessions with Tanya's therapist prior to adoption, and they were advised of specific problems they might encounter with Tanya's
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placement. They were made aware of Tanya's past physical abuse and prepared far any possible initial testing behavior. Tanya's contact with her therapist was terminated when she went to her new home. Her adoptive parents were encouraged to recontact the therapist should problems arise. During her last play sessions Tanya talked freely of her new parents. She was prepared for separation from her therapist and her foster parents well in advance, but she verbalized very little regarding this separation in her play sessions. At 1 month follow-up by phone, the adoptive mother described everything as going fine. However, at 2 months the adoptive parents requested consultation. The adoptive father was concerned because he wanted to play with Tanya and was frequently rebuffed. He described being embarrassed in front of relatives when Tanya would prefer closeness to others and reject him. The adoptive mother expressed her concern about Tanya's rejection of the father but related that her relationship with the girl was fine. In the course of interviews, the father's intense desire to succeed as a parent became obvious. He talked of joining his daughter in the sandbox, attempting to tussle and wrestle with her. Both parents were reminded of Tanya's previous abuse by a male and how extreme physical closeness by a new male in her life could be threatening. Also, the father was encouraged not to see Tanya's rejection as a reflection of his ability to parent. The father was instructed to make himself available to his daughter, but to allow her to initiate close physical play or contact. Both parents accepted the interpretation and recommendations. They have given follow-up to our clinic since that time and report an improvement in father-daughter relations. The four major crisis-oriented goals in this case were: (a) helping to maintain Tanya's foster placement until adoption by way of counseling the foster mother; (b) regular consultation with the local agency to assist them in implementing an appropriate adoptive placement in the shortest time possible; (c) allowing Tanya to work through her present separation crisis in play therapy; and (d) counseling the adoptive parents regarding how best to handle Tanya's adjustment and their own feelings about parenting. Discussion A therapeutic approach based upon the perception of a placed child as a h u m a n being in crisis has b e e n p r e s e n t e d . T h e p l a c e d child's s y m p t o m s are seen as a " d i s e q u i l i b r i u m r e s p o n s e " t o his d e f i n i t i o n o f t h e p l a c e m e n t s e p a r a t i o n as t h r e a t e n i n g t o his s e c u r i t y and e m o t i o n a l homeostasis. Crucial t o t h e r a p y is the child m e n t a l h e a l t h p r o f e s s i o n a l ' s awareness o f t h e p l a c e d child's d e v e l o p m e n t a l stages a n d his e m o t i o n a l needs, t o g e t h e r w i t h an u n d e r s t a n d i n g o f his v u l n e r a b i l i t y in t h e face o f s e p a r a t i o n f r o m p a r e n t a l figures. This k n o w l e d g e can be u s e d effectively in guiding t h e child, p a r e n t s , a n d agencies t o r e s o l u t i o n o f t h e child's s e p a r a t i o n crisis. In t h e situations p r e s e n t e d , B e t t y ' s w i t h d r a w a l , R o s a l i n d ' s destructiveness, a n d T a n y a ' s t e m p e r t a n t r u m s w e r e seen as s y m p t o m s signaling a crisis. In e a c h case, e f f o r t s were e x p e n d e d in t h r e e directions:
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(a) directive guidance toward enabling parents, foster parents, or agencies to stabilize the child's environment; (b) helping parents to confront and deal with their own feelings as these interfered with a happy and loving relationship with the child; and (c) play therapy to assist the child in coping with the confused and frightening emotions that attend the experience of placement separations. This approach is seen as a form of primary prevention, an a t t e m p t to forestall the potential damage of a child's failure to resolve effectively the unremitting pain of a placement separation crisis. In the words of Dr. Gilbert Kliman, Director of the Center for Preventive Psychiatry in White Plains, New York, these measures may assure that children are n o t left as "hurting silent islands" by crisis tasks incompleted [11: p. 24]. References 1. Mahler M: On sadness and grief in infancy and childhood. Psychoanal Study o f the Child 16:332-351, 1961. 2. Bowlby J: Separation anxiety. Int JPsychoanal 41:69, 1960. 3. Bowlby J, Robertson J: Responses of young children to separation from their mothers. Courrier du Centre Internat de l'enfance 2:31, 1952. 4. Bowlby J, Ainsworth M, Boston M, et al: The effects of mother child separation: A follow-up study. Brit JMed Psychol 29:211, 1956. 5. Freud A, Dann S: An experiment in group upbringing. Psychoanal Study of the Child 6:127-168, 1950. 6. Parad H: Crisis intervention. Encyclopedia of Social Work. Albany, NY, NASW, 1971. 7. Goldstein J, Freud A, Solnit A: Beyond the Best Interests of the Child. New York, Free Press, 1973. 8. Littner N: Some Traumatic Effects o f Separation and Placement. New York, Child Welfare League of America, Inc, 1956. 9. Caplan G: Principles of Preventive Psychiatry. New York, Basic Books, 1964. 10. Lindemann E: Symptomatology and management of acute grief. Amer J Psychiat 101:7-21, 1944. 11. Michelmore P: Primary prevention so children won't be silent islands. Mod Med, 18-24, August 19, 1974.
Phillip M. Clifton, MD Jane W. Ransom, MSW, ACSW University o f Virginia Medical C~nter
A B S T R A C T : This paper presents an approach to working with the diagnostic and therapeutic challenges posed by the "placed child." A thorough knowledge of child development, combined with awareness of the basic tenets of crisis intervention, offers the child mental health professional guidelines to assist placed children in coping with their uncertain environment. Parents and agencies are guided toward stabilizing the child's environment, while the child is maintained in play therapy to assist him in coping with the confused and frightening emotions that attend the experience of placement separation. Three clinical cases are presented that illustrate an active short-term therapy, a form of primary prevention attempting to forestall the potential damage of unresolved placement separation crises.
Child mental health professionals are familiar with the often difficult separations and adjustments children experience when they are placed in institutions, taken into foster and adoptive homes, or caught up in custody battles that result from marital separation and divorce. These children make up a substantial proportion of clinic populations. The importance of stable and consistent parenting to a child's development is well substantiated in the literature. Margaret Mahler [ 1], in formating infantile psychosis, studied the normal development of the mother-child relationship. She concluded that a need-satisfying mother-infant relationship during the 1st year of life is essential for normal development. The infantile and early childhood suffering resulting from mother-child separations in such distressing circumstances as maternal death or serious illness of mother or child has been studied by John Bowlby [2, 3, 4], and the difficult adjustments of children separated from their families during wartime have been reported by Anna Freud and Dorothy Burlingham [ 5]. Dr. Clifton is a Resident in Child Psychiatry, Division of Child and Adolescent Psychiatry, University of Virginia Medical Center, Charlottesville, Virginia 22901. Child Psychiatry and Human Development
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The environment in which a child develops is a variable of crucial significance in formulating any therapeutic approach for children. But what is the role of child mental health professionals in helping the placed child to reach his or her full potential and to avoid the neurotic or sociopathic aftermath of multiple placements and general environmental confusion? This paper will present a therapeutic approach to working with the placed child posited on the child mental health professional's responding to a child's needs in the midst of crisis. Howard Parad [6: p. 197] delineates the components of crisis as: (a) an identifiable stressful event; (b) the individual's perception of the event as threatening to "such vital goals as life, security, and affectional ties"; (c) a disorganization and disequilibrium response; and (d) the coping and intervenrive tasks involved in resolving the crisis. Considering the stressful event to be a child's actual or threatened separation from parent figures, the therapeutic approach presented involves the need for sensitive awareness of h o w the child perceives this separation and his uncertain environment. One important aspect of this approach is an awareness of the child's emotional and cognitive development. Joseph Goldstein, Anna Freud, and Albert Solnit [7] argue very effectively in their recent publication, Beyond the Best Interests of the Child, that our present legal system is less than fully cognizant of the child's developmental needs and his singular way of responding to his environment, differing from that of adults. These authors point o u t that the y o u n g child sees no merit to the claims of blood relationship, but instead develops emotional ties to those who fulfill his daily needs for physical and emotional nurturance. The passage of time, for the y o u n g child, is experienced according to the "urgency of [his] instinctual and emotional needs" [7: p. 11] with extreme reaction to lengthy separations and unfulfilled needs. Ner Littner [8], consultant psychiatrist for the Illinois Children's Home and Aid Society, in 1956 studied the traumdtic effects upon a child of separation and placement. He describes the child's experience of abandonment, encompassing feelings of loss, humiliation, and worthlessness. He speaks of the child's a t t e m p t to handle his anger and his total helplessness by holding himself, and some specific wickedness, responsible for the separation. For his anger and wickedness the child fears and expects retaliation, often seeing his new parents as the instrument of his punishment. Once some initial adaptation to his placement has been achieved, the child, according to Littner, must further cope with his dangerous wish to love his new parents, and his
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fear that he will be rejected by them. Littner emphasizes the importance of the child care professional's being adept at identifying the feelings a child experiences in placement. He comments, "I would like to remind y o u of one of the greatest difficulties that we experience in the placement of a child--namely, our problems a b o u t seeing things through his eyes, and of adequately understanding and being sensitive to the real meaning of what he is trying to tell us, through his verbal and non-verbal behavior" [8:p. 31]. It would appear that the child experiencing placement separations is likely indeed to define these events as threatening to his life, security, and affectional ties. The s y m p t o m s that bring the placed child to professional attention represent the "disequilibrium response" of an individual in a crisis state. The recently developed crisis literature gives therapeutic guidelines that can be used to assist the child and his family in accomplishing the necessary coping tasks. In discussing the concept of "primary prevention," Gerald Caplan [9: p. 26] speaks of lowering the incidence of mental disorder by "counteracting harmful circumstances before they produce illness." Littner [8: p. 20] refers to two factors that affect the a m o u n t of personality damage resulting from placement separations: the child's age at separation, and the extent to which he represses his painful feelings. It is vital to the y o u n g child's emotional development that he be helped to deal with his placement experience in such a way that he achieves an adaptive resolution of this crisis. Caplan [9: p. 41] describes the crisis state as involving "the emergence of old problems accompanied by a significant emotional reaction," indicating that the problems "were not satisfactorily dealt with in the past." Erich Lindemann's [10] classic study of grieving patients {including those bereaved by the 1943 Coconut Grove nightclub fire in Boston) discovered in his sample some patients whose severe reaction to the recent loss signified an unresolved grief reaction from many years ago. In helping bereaved patients to accomplish their normal "grief w o r k " and to achieve a healthy readjustment, Lindemann and his colleagues established the p r o t o t y p e of "preventive" crisis intervention. In the idiom of Caplan's Principles of Preventive Psychiatry, the placed child is at special risk and in need of preventive attention lest the unresolved crisis of his placement separations be the cornerstone for later disturbed functioning. The crisis-oriented approach offers a format for clinical intervention with the placed child and his family that should help to achieve an adaptive resolution of the crisis of separation. First, there is an ac-
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c e p t a n c e o f explicit, time-limited goals, highly i m p o r t a n t to the child w h o s e need for security a n d e m o t i o n a l gratification is pressing. Seco n d , the therapist assumes an active role, using his p s y c h o l o g i c a l and p s y c h o a n a l y t i c b a c k g r o u n d t o assess the situation, t o e n c o u r a g e o p e n expression o f feelings related t o the crisis, and t o m o v e into direct int e r p r e t a t i o n a n d o p e n c o n f r o n t a t i o n , as a p p r o p r i a t e , with the child and his family. Third, the t h e r a p i s t utilizes such specific crisis-dealing t e c h n i q u e s as direct advice and e n v i r o n m e n t a l m a n i p u l a t i o n . Case R e p o r t s
Case 1 Betty, 6 years old, was referred for psychiatric evaluation by her adoptive parents, Mr. and Mrs. G., because Betty "didn't seem to be fitting into the family." When Betty's adoptive parents were seen together for an initial evaluation interview, they presented the problem as being one of "Betty's not sure she wants to be our little girl." Three months prior to the G.'s presentation for evaluation, 10year-old Gregory, 9-year-old Johnny, and 6-year-old Betty had been placed for adoption in the G.'s home. The adoption of the three siblings had not been finalized at the time of referral. Mr. and Mrs. G., a childless couple in their early 30s, had decided to adopt children approximately 2 years prior to being seen at this clinic. Mr. G., an engineer, and Mrs. G., a medical technologist, had cared for a number of foster children successfully in their home, and they felt they were ready to have a permanent family. The three children were abandoned by their biologic mother 5 years previously and had been in group foster placement prior to their trial adoptive placement with the G.'s. Past history. Six-year-old Betty remembered no family other than her foster parents. The foster father died when Betty was 3 years old, so that her only longterm parental relationship was that with the foster mother. This foster mother is described in a social study by the local welfare agency as being obviously partial to Betty over the other foster children in her home. Betty slept with the foster mother after the foster father's death, and was often found sitting in the foster mother's lap when the social workers visted the home. Adoption was sought for Betty and her brothers because the foster mother was in her mid-60s, with health problems that compromised her ability to care for the children in her home. Betty experienced more difficulty in making the separation from her foster mother than her older male siblings. In the initial 3 to 4 weeks with Mr. and Mrs. G., Betty was enuretic, had nightmares, and was noted by Mr. and Mrs. G. to be shy around other children and not as outgoing as her brothers. The G.'s were aware of Betty's preferential treatment in her previous foster placement, and they felt that this accounted for some of her difficulty in making the adjustment in their home. However, when Betty began, in the 2nd month of her placement with the G.'s, to express a desire to go back to the foster mother the G.'s were shaken, and in their initial interview with the therapist Mr. G. said, "We don't want to make Betty live with us if she doesn't want to be in our home." The G.'s questioned if they should proceed to finalize the adoption for Betty. They had
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discussed with Betty the possiblity of her leaving their home and her two brothers remaining with the G.'s. T r e a t m e n t a n d clinical course. When Betty was seen for evaluation, she presented a pleasant physical appearance, with long blonde hair and an angelic face. However, in the playroom she was inhibited and seemed frozen by anxiety. She remained in one chair throughout her initial interview, never venturing out to examine any of the playroom material. She was most spontaneous when she talked of two cats she had at Granny's house and how she missed them. After the initial interviews with Betty and her parents, it seemed crucial to formulate a therapeutic approach that would help both Betty and her adoptive parents deal with the immediate adjustment problems. The G.'s were anxious about falling in their new role as parents, and they saw Betty's continued talk about her foster mother as evidence of their failure to parent adequately. They were inappropriately allowing Betty to make the decision of whether to go or stay, which only heightened the girl's anxiety. Betty's anxiety, manifested by wetting, nightmares, and tenseness, was an indication of the repressed feelings regarding her separation from her overprotective foster mother and placement with her new adoptive parents. Contrary to what Betty's adoptive parents thought, her difficulty in accepting them had little to do with their ability to parent. Betty feared closeness to new parenting figures. For Betty, loyalty to new parents implied disloyalty to old, and the fear of being rejected again kept her from becoming emotionally close to the G.'s. An interpretive interview was held with the adoptive parents, and they agreed on a 2-month period of crisis-oriented work that would include weekly play therapy sessions with Betty and biweekly parental counseling with the G.'s. The therapeutic goals were: (a) play therapy for Betty with the goal of allowing her to express repressed feelings about separation from her "Granny" and also to allow the therapist to monitor Betty's emotional adjustment to her new environment; and (b) counseling of adoptive parents--to help them deal with their feelings of inadequacy and to help them better understand the meaning of Betty's behavior as she attempted to adjust to her new home. During the course of eight sessions in the playroom, Betty changed markedly. She gradually became more animated in her play. During the earlier sessions she had two mothers in her dollhouse, reflecting her ambivalence regarding giving up her foster mother and accepting her new adoptive mother. However, as the sessions progressed, Betty began to give evidence that she was accepting her new parents. She played out more sequences involving "mommy and daddy" and on her last play session drew a picture of her new family for the therapist. The adoptive parents used their family therapy sessions effectively. They were open in discussing their frustations in not being totally accepted by Betty, and they were able to accept the therapist's assisting them in understanding Betty's behavior, and not allowing their frustrations to bring about withdrawal, rejection, or retaliation against Betty. The parents did become more relaxed and during the course of counseling sessions proceeded with finalizing adoption of all three children. Approximately 1 year after their initial contact for evaluation of Betty, the G.'s recontacted the therapist. They had moved from the local area and reported that in the adjustment to a new living situation Betty again had occasional enuresis and withdrawal from the family. They asked for recommendations on handling these problems. In the most recent contact, the G.'s had accepted Betty as
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part of their family. The questions they asked reflected their concerns about their daughter's development. They were more confident and less threatened by possible failure as parents.
Case 2 Five-year-old Rosalind was referred for evaluation by a public health nurse in response to her stepmother's request. Rosalind's presenting symptoms were "lying, wetting her pants, and breaking toys." Past history. Rosalind is the youngest child born to her biologic parents, whose stormy marriage ended in their separation when Rosalind was 15 months old. Together with her mother and her two brothers, Rosalind joined the maternal grandparents' home. Two years later her brothers' custody was transferred to their father and his new wife, but Rosalind's fate remained unsettled as she shifted about from grandparents to mother to father, depending on her mother's ability and desire to care for her. At the time of referral she had lived continuously with her father and stepmother for about a year, but during each visit her mother promised Rosalind, " I ' m going to take you just as soon as I can get things together." From Rosalind's point of view, chaos reigned in both the families that accorded her a precarious position in their midst. A few weeks prior to referral, during a visit with their mother, Rosalind and her brothers witnessed a violent scene between their mother and her third husband, which resulted in the children's precipitous return to their father's home. At the same time, Rosalind's stepmother struggled with a crisis of her own. The birth of a child to Rosalind's biologic mother triggered in the stepmother unresolved feelings of grief and jealousy from her own miscarriage several months before. This, together with Rosalind's seeming rejection of her as a mother, served to mobilize all her feelings of maternal failure and personal worthlessness. The result was Rosalind's realistic perception of an angry stepmother who, at any moment, might eject her from the family. Treatment and clinical course. Rosalind's intermittent episodes of regressed behavior were seen as reactive to her confused environmental setting, and to the threat this situation represented to her security and affectional needs. The goals established to deal with Rosalind's "disequilibrium response" were: (a) to encourage her three parents to effect a stabilization of her environment; (b) to help her stepmother resolve some of her own anger and grief, and develop a less conflicted relationship with Rosalind; and (c) to enable Rosalind, during the course of play therapy, to cope with the confusion, anger, and apprehension that beset a child in so chaotic a world. The first goal, the vital necessity of settling the issue of Rosalind's custody, was shared in separate interviews with natural mother and with father and stepmother. Each parent was encouraged to express directly his or her ambivalent feelings about Rosalind's future. It developed that her biologic mother, although guilty about relinquishing custody, felt too enmeshed in her own problems to handle any direct commitment to the child. On the other hand, her father and stepmother expressed the desire for Rosalind's custody. They were seen by the therapists as offering her greater strength and security at that time. With open clarification of these issues, and with the therapists' support for settling the cus-
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t o d y matter in favor of father and stepmother, Rosalind's stepmother was able to set in motion the necessary action for transfer o f custody. In accordance with the second goal of helping Rosalind's stepmother to resolve her own feelings and to develop a more positive relationship with Rosalind, crisis intervention therapy was instituted with the stepmother, Mrs. E. She discussed her anger and sadness about her own mother's disapproval o f her recent pregnancy, as well as her extreme grief, heretofore scarcely expressed, at miscarrying this child. She felt sure the lost baby had been a girl "because I wanted a girl so badly," and indicated that a friend had told her "once you have a daughter, you become closer to your own mother." Mrs. E. freely expressed her resentment toward Rosalind's biologic mother, who had been able to deliver a healthy child. Following several months of futile efforts to conceive another child, Mrs. E. became pregnant--about 2 months after Rosalind's referral to the clinic. She experienced considerable fear of another miscarriage in response to relatively minor physical symptoms, but at the completion of her first trimester and her doctor's prognosis of a successful pregnancy, she appeared radiantly in maternity clothes for her next appointment. Rosalind's stepmother discussed at length her wish to be close to Rosalind, and her desire that Rosalind should be "like her," as they were the two "ladies" in the family. She angrily related her hurt at Rosalind's apparent rejection, such as the child's preferring the dresses her mother bought her to those Mrs. E. made for her, and Rosalind's possessive feelings a b o u t her natural mother's new infant. In time, however, her anger toward Rosalind began to subside as she ventilated her disappointment about the child's failure to fulfill the role of her daughter and as she better understood Rosalind's conflicting need for her stepmother and loyalty to her natural mother. Although again heavily invested in delivering a girl, Mrs. E. showed much concern and understanding about Rosalind's reaction should this be the case. She also engaged in some "role rehearsal" of how she would handle Rosalind's feelings and behavior, whether the baby should be a girl or a boy. Rosalind's playroom sessions were directed toward accomplishment of the third goal, enabling her to resolve her confused and angry feelings. In the playroom, Rosalind was preoccupied with domestic scenes--cooking, cleaning, caring for infant dolls. She asked what had happened to the missing baby in the kangaroo's pouch and, with sad affect, related that her " m a m a had a baby that died." Initially, when the therapist a t t e m p t e d to reflect these feelings, she hastily withdrew from the topic. A week after a new brother was born to her natural mother, Rosalind announced, "Our baby has come," and proceeded to display regressed, infantile behavior. Her high-pitched, immature speech and mimicked toddler gait appeared in response to discussion of new babies in her extended family constellation. Rosalind verbalized her confusion about "two mamas and two daddies," sometimes appearing uncertain as to who fitted what title in her array of parental figures. She furiously described her "other mother's husband" who threatened her mother with a knife, and bailing up her fists, said, " I f he ever does it again, I'll get him." She brought a t o y alligator into the playhouse, and guiltily asserted that it would eat up mother, father, and baby. Early in her therapy, Rosalind indicated that if given a choice, she would rather live with her maternal grandmother. As her situation stabilized, she later said that she likes it with "this m a m a " (stepmother) and expressed concern
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about the ill feelings between her two mothers because she "wanted them to be friends." When the custody transfer had been accomplished, Rosalind joyfully announced her new status to the therapist: "I'm going to be staying with my mama and daddy; they told me!" Within a short time, she began to relinquish her regressive behavior and became increasingly tolerant of closeness to her stepmother. She continues to adjust well in school and to experience a warm, caring relationship with her stepmother. She is devoid of symptoms, with the exception of rare wetting episodes felt by her stepmother to be related directly to difficult visits with her biologic mother. The stepmother has shown increasing emotional investment in Rosalind, viewing any behavior problems with compassionate concern and handling them appropriately.
Case 3 Tanya, 5 years old, was brought to the emergency room in her local area during the winter of 1973 by a baby-sitter who was concerned about Tanya's high fever, vomiting, diarrhea, and bruises on her body. Tanya was admitted to the local community hospital and transferred several days later to a university medical center for further inpatient evaluation. The etiology of her fever and gastrointestinal symptoms was found to be shigellosis. She was begun on appropriate antibiotic therapy. Her physical examination also revealed multiple large ecchymoses over the legs, thighs, buttocks, and lower back. Tanya was seen in psychiatric consultation while she was hospitalized on the medical center pediatric ward. Tanya was presenting as a management problem on the ward. She was described as "crying uncontrollably during the evening hours, often waking during the night and found standing in the corner of her bathroom crying and not responding to the reassurance offered by the staff. When first seen, Tanya presented as an average-sized, blonde-haired 5-yearold, found in an infectious disease isolation room on the pediatric ward. She was cooperative and engaging with the interviewer, speaking quite distinctly and answering any direct questions in a pseudomature manner. She talked freely about her stepfather's beating her and attempting to choke her. There was no apparent change in her bright, sunny affect when she described this physical abuse by her stepfather. She became tearful when the interviewer departed the room, pleading for a return visit. The consultant's initial impression after the first interview with Tanya was that her nighttime fears and withdrawal during the evening hours on the pediatric ward were reactive to the abusive home environment she described in the initial interview. Investigations of the home environment were instituted both by the Child Protection Committee of the university medical center and the welfare agency in the girl's local area. Past history. The protective service investigations revealed that Tanya had been the product of an unwanted pregnancy, born to an unmarried mother. Tanya had spent her first years in a rural environment, where her maternal grandmother was her primary caretaker. Because of her grandmother's "bad health," Tanya had come to live with her biologic mother and stepfather for the 8 months prior to her hospitalization. Investigation by the Child Protection Committee resulted in Tanya's custody being given to the local department of social services,
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and Tanya being placed in foster care. Subsequently, the biologic mother relinquished parental rights, making it possible for the local agency to place Tanya for adoption. Initially, Tanya's foster mother found her very difficult to handle. Tanya was described as having fits of uncontrollable anger during the day and screaming resistance at bedtime. Tanya would awaken frequently at night, screaming in terror, often telling the foster mother, "My daddy puts a pillow over my head and I am scared while I am asleep." She also told the foster mother of having to lie down facing her stepfather and being beaten, and if she cried out, turned over on her back and being beaten some more. Tanya never mentioned her mother's physically abusing her. While the foster mother felt great sympathy for Tanya, her behavior was difficult for the family to tolerate. T r e a t m e n t a n d clinical course. One of the first crisis-oriented goals in this case was to help maintain Tanya's foster placement through frequent counseling with the foster mother. Tanya's intolerable behavior was discussed with the foster mother as it related to Tanya's past physical abuse and also to her present emotional trauma of uncertainty in a new environment. In addition to working through past traumatic experiences, Tanya's behavior was interpreted to the foster mother as a means of testing her acceptance in the new foster family. The foster mother was supportively encouraged to be firm with Tanya regarding bedtime, temper tantrums, and aggressive behavior. In addition to work with the foster mother, Tanya was seen in individual play therapy sessions, allowing her to use play as a means of working through some of her immediate separation anxieties and feelings of abandonment and loss. In her initial play sessions, Tanya maintained her bright, happy affect, often singing and busying herself with domestic play, such as cooking and cleaning. However, after the initial session, she began to talk of her stepfather's physical abuse. In contrast to her presentation on the hospital ward, Tanya now had a saddened affect as she talked of the past physical abuse. Tanya also played out sequences regarding her foster mother, whom she would alternately see as sinister and bad, and loving and giving. Tanya obviously wanted to trust her benevolent, understanding foster mother, but she also displaced onto the foster mother the unloving, abusive characteristics she had come to associate with parenting figures. Tanya related well to her male therapist, seeming anxious to please and often coy and flirtatious in her manner. She was described by her foster mother as "all girl," loving to dress up and be pretty. She was noi~iced competing with other children in the foster home for the foster mother's attention. As work with Tanya and her foster mother progressed, Tanya's symptoms improved, and she became integrated into the foster family. The foster mother's impulse to send Tanya to another home was forestalled. Consultation to the local social service agency recommended adoptive placement in the shortest time possible to prevent Tanya and her foster mother from developing a relationship of such depth that Tanya's adoptive placement would constitute another traumatic separation. Fortunately, several appropriate adoptive couples were available, which facilitated Tanya's early placement. The adoptive parents selected were a childless couple in their mid-30s who were "taken with Tanya from the beginning." They visited with Tanya on several weekends before taking her to their home for final placement. The adoptive parents were seen in counseling sessions with Tanya's therapist prior to adoption, and they were advised of specific problems they might encounter with Tanya's
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placement. They were made aware of Tanya's past physical abuse and prepared far any possible initial testing behavior. Tanya's contact with her therapist was terminated when she went to her new home. Her adoptive parents were encouraged to recontact the therapist should problems arise. During her last play sessions Tanya talked freely of her new parents. She was prepared for separation from her therapist and her foster parents well in advance, but she verbalized very little regarding this separation in her play sessions. At 1 month follow-up by phone, the adoptive mother described everything as going fine. However, at 2 months the adoptive parents requested consultation. The adoptive father was concerned because he wanted to play with Tanya and was frequently rebuffed. He described being embarrassed in front of relatives when Tanya would prefer closeness to others and reject him. The adoptive mother expressed her concern about Tanya's rejection of the father but related that her relationship with the girl was fine. In the course of interviews, the father's intense desire to succeed as a parent became obvious. He talked of joining his daughter in the sandbox, attempting to tussle and wrestle with her. Both parents were reminded of Tanya's previous abuse by a male and how extreme physical closeness by a new male in her life could be threatening. Also, the father was encouraged not to see Tanya's rejection as a reflection of his ability to parent. The father was instructed to make himself available to his daughter, but to allow her to initiate close physical play or contact. Both parents accepted the interpretation and recommendations. They have given follow-up to our clinic since that time and report an improvement in father-daughter relations. The four major crisis-oriented goals in this case were: (a) helping to maintain Tanya's foster placement until adoption by way of counseling the foster mother; (b) regular consultation with the local agency to assist them in implementing an appropriate adoptive placement in the shortest time possible; (c) allowing Tanya to work through her present separation crisis in play therapy; and (d) counseling the adoptive parents regarding how best to handle Tanya's adjustment and their own feelings about parenting. Discussion A therapeutic approach based upon the perception of a placed child as a h u m a n being in crisis has b e e n p r e s e n t e d . T h e p l a c e d child's s y m p t o m s are seen as a " d i s e q u i l i b r i u m r e s p o n s e " t o his d e f i n i t i o n o f t h e p l a c e m e n t s e p a r a t i o n as t h r e a t e n i n g t o his s e c u r i t y and e m o t i o n a l homeostasis. Crucial t o t h e r a p y is the child m e n t a l h e a l t h p r o f e s s i o n a l ' s awareness o f t h e p l a c e d child's d e v e l o p m e n t a l stages a n d his e m o t i o n a l needs, t o g e t h e r w i t h an u n d e r s t a n d i n g o f his v u l n e r a b i l i t y in t h e face o f s e p a r a t i o n f r o m p a r e n t a l figures. This k n o w l e d g e can be u s e d effectively in guiding t h e child, p a r e n t s , a n d agencies t o r e s o l u t i o n o f t h e child's s e p a r a t i o n crisis. In t h e situations p r e s e n t e d , B e t t y ' s w i t h d r a w a l , R o s a l i n d ' s destructiveness, a n d T a n y a ' s t e m p e r t a n t r u m s w e r e seen as s y m p t o m s signaling a crisis. In e a c h case, e f f o r t s were e x p e n d e d in t h r e e directions:
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(a) directive guidance toward enabling parents, foster parents, or agencies to stabilize the child's environment; (b) helping parents to confront and deal with their own feelings as these interfered with a happy and loving relationship with the child; and (c) play therapy to assist the child in coping with the confused and frightening emotions that attend the experience of placement separations. This approach is seen as a form of primary prevention, an a t t e m p t to forestall the potential damage of a child's failure to resolve effectively the unremitting pain of a placement separation crisis. In the words of Dr. Gilbert Kliman, Director of the Center for Preventive Psychiatry in White Plains, New York, these measures may assure that children are n o t left as "hurting silent islands" by crisis tasks incompleted [11: p. 24]. References 1. Mahler M: On sadness and grief in infancy and childhood. Psychoanal Study o f the Child 16:332-351, 1961. 2. Bowlby J: Separation anxiety. Int JPsychoanal 41:69, 1960. 3. Bowlby J, Robertson J: Responses of young children to separation from their mothers. Courrier du Centre Internat de l'enfance 2:31, 1952. 4. Bowlby J, Ainsworth M, Boston M, et al: The effects of mother child separation: A follow-up study. Brit JMed Psychol 29:211, 1956. 5. Freud A, Dann S: An experiment in group upbringing. Psychoanal Study of the Child 6:127-168, 1950. 6. Parad H: Crisis intervention. Encyclopedia of Social Work. Albany, NY, NASW, 1971. 7. Goldstein J, Freud A, Solnit A: Beyond the Best Interests of the Child. New York, Free Press, 1973. 8. Littner N: Some Traumatic Effects o f Separation and Placement. New York, Child Welfare League of America, Inc, 1956. 9. Caplan G: Principles of Preventive Psychiatry. New York, Basic Books, 1964. 10. Lindemann E: Symptomatology and management of acute grief. Amer J Psychiat 101:7-21, 1944. 11. Michelmore P: Primary prevention so children won't be silent islands. Mod Med, 18-24, August 19, 1974.
