Six-year-old Emma’s* blue eyes light up when Evy Ezpinoza, her therapist, walks through the door. The little girl and her adoptive mother sit side-by-side at a table in a playroom where their parent-child interaction therapy session is coming to a close. But Emma’s expression quickly changes when Evy explains, in a calm, concerned tone, that they don’t have time to play today.
Emma and Evy often get a few minutes of “special play time” at the end of Emma and her mom’s therapy sessions at a clinic called TIES (which stands for training, intervention, education and services) for Families South Bay in Torrance, Calif.
Wearing a pink t-shirt and a high ponytail, Emma tells Evy that she feels sad, her quiet voice barely picked up by the microphone in the room. Emma then climbs into her mom’s lap and leans into her for a hug. Evy thanks Emma for using her words to express her feelings, at the same time waving and pointing to make sure that mom, Jane,* recognizes the significance of Emma turning to her for comfort—evidence that Emma’s attachment to her mother of three years is improving.
Emma spent two years in foster care before finding her adoptive family and has had behavioral challenges, including aggression. Not much more is known about the first few years of her life except that she was removed from her birth family at six months.
Two weeks ago, during their last therapy session, Emma and Jane played with cat puppets. Emma insisted that her puppet only spoke Spanish and couldn’t understand what her mom’s puppet was saying. She also spent much of the session looking down at the toys or into the two-way mirror in the playroom, rarely making eye contact with Jane.
“Mom often doesn’t see the changes, so that’s why I’m pointing it out,” Evy said later.
Jane, who appears to be in her early 40s and has a 9-year-old biological child in addition to Emma, has been struggling with depression for some time, according to Evy, and often withdraws in response to Emma’s behavior in and out of the therapy playroom. This makes it more difficult to connect with Emma and to progress through the phases of parent-child interaction therapy, according to Lara Litvinov, Evy’s supervisor at TIES.
“When kids feel safe and have special playtime with a parent, the kids will start playing out things, and the parent’s impulse is to just shut it down,” said Litvinov.
“What happens is that it affects their ability to keep engaging with their child and seeing the positive pieces, seeing any behaviors change, because the adoption issues are getting triggered, or there’s issues with the birth family still,” she said.
Held in a secure suite inside a large corporate complex, this is the 12th session for Emma and her mom focusing on child-directed interaction—the first phase of parent-child interaction therapy (PCIT). Standard PCIT practice calls for seven to 10 such sessions before moving on to the second phase.
Although little Emma’s wide eyes and playful attitude help make light of the therapy session, the reality is that for her, and for thousands of adopted children like her who may exhibit aggression and other difficult behaviors, adoption does not guarantee a permanent place at her family’s dinner table.
The precise number of adoptions that end badly is unknown, but as a Reuters series in 2013 demonstrated, there are too many families in desperate situations who take extraordinary, and often questionable, action when they fail to bond with their adoptive children.
It’s clear that these families need more support from mental health professionals, which may be forthcoming as a result of last year’s federal bill that requires states to re-invest a percentage of adoption incentive payments in post-adoption services.
But even if the funding becomes available, how do therapists know whether a particular therapeutic approach is effective? How can service providers replicate a model that isn’t truly a model?
Parent-child interaction therapy, which is unique in that parents receive live coaching through a headset while interacting with their child, is a “manualized intervention”—meaning practitioners follow a specific sequence of activities that has been shown by researchers to be highly effective. PCIT is supported by decades of research, much of which has been conducted by a team at the Parent-Child Interaction Therapy Training Center at the University of California, Davis, and is based on principles of social learning, behavioral and attachment theories.
PCIT has already been adapted for families involved in the child welfare system. Researchers have also evaluated it as an intervention for adoptive families, but only on a small scale.
As is often the case with social programs, the external validity—meaning the degree to which a study’s findings can be generalized to populations other than the study’s sample—of any one therapeutic approach is difficult to ascertain.
Practitioners in the field confirm that sometimes the most challenging aspect of using an evidence-based program to help adoptive parents and children work through the difficult process of bonding as a family is that every family comes with their own set of issues and potential.
“This work is so very complex. It’s not one-size-fits-all,” said Debbie Riley, one of the founders of the Center for Adoption Support and Education (CASE) in Burtonsville, Maryland.
CASE provides mental health services for about 500 adopted children each year and advocates for an adoption-competent mental health workforce.
“You really have to be very careful,” Riley said. “Each family’s story is unique and each child is unique. You have to be inclusive of the family and not work with children in isolation—that’s key.”
This leaves practitioners like Evy Espinoza in a tough position: In order to best serve their clients, they may have to deviate from the proven model.
“That’s where we get into the dilemma around the fidelity of the treatment protocol,” Riley said. “What really is the efficacy that you’re evaluating if you’re modifying it and changing the protocol? What’s really effective with that family?”
For example, in PCIT there’s a disciplinary action called “swoop-and-go” that is called for when a tantrum-throwing child is unable to calm down. Swoop-and-go requires that the playroom be cleared of all furniture, toys and people, and the child is asked to remain in the room alone while under close supervision by the therapist and parent, who wait just outside the door, while remaining within the child’s sight.
Therapists who are engaged in the delicate work of helping adoptive children bond with their new parents are wary of any activity that might re-traumatize the child or otherwise jeopardize that budding attachment.
“Sometimes it’s hard – we were trained by UC Davis, and now I’m saying you should do it differently,” Litvinov of TIES said. “Swoop-and-go was very hard for our staff to be able to accept, given the fears of separation for these kids, and the experiences of neglect.
“We were very concerned about some re-traumatization. We had many discussions with UC Davis and others that it wasn’t re-traumatizing, but we still did not think it was helpful for [our clients], especially for a newly attaching family.”
TIES for Families is both a clinic and training facility directly operated by the Los Angeles County Department of Mental Health in partnership with UCLA. The clinic serves adoptive families as well as reunifying birth families and foster families.
Because the TIES clinic has access to a variety of funding streams, its staff is able to offer customized, long-term support to its clients, which is highly unusual for a county-operated agency.
This is what makes it possible for TIES to expand the PCIT program and to include extra sessions just for parents.
“For swoop-and-go, we’re still working on it,” Litvinov said.
“We generally don’t do it for our adoptive families. We’ll take all the toys out of the room and we’ll stay in the room with the parent and child. We’ll take the tables and chairs out if we have to, but we generally don’t take the parent out of the room.”
Litvinov and her staff are trained in a number of therapeutic approaches based on attachment theory, including child-parent psychology or CPP.
“Having been trained in all these attachment-based models, I can actually see how we can bring them together,” Litvinov said. “I can really see how it doesn’t have to be one versus the other, CPP or PCIT, and actually incorporating it makes much more sense for most parents, but especially for adoptive parents.”
Researchers like Anthony Urquiza of UC Davis suggest that the belief among therapists that adoptive children need “attachment therapy” prevents PCIT from being more widely used with adoptive families. At the same time, however, researchers have found, from a preliminary study, evidence indicating that PCIT aligns with the objectives of attachment therapy and may be used effectively with this population.
In a 2014 paper published in Children and Youth Services Review, Urquiza, along with two other researchers, found that among 85 children participating in PCIT—all of whom had child maltreatment histories—there were improvements in emotion regulation and social skills, both of which are primary goals of attachment-based therapies.
The larger problem then, from Riley’s perspective, is not whether treatments like PCIT are appropriate for adoptive families. The issue is the lack of funding to support research that would more definitively determine what’s working for families and what isn’t, so that the most effective approaches can be made available to more families.
“I think that’s where things are getting a little muddied, and there’s more research to be done,” Riley said.
“We’ve got to align fiscal with practice and policy in the hope that we can make these services available to more families, when we find the ones that are most effective,” she said.
Back in the playroom, therapist Evy spends a few minutes cajoling Emma’s mom into returning to TIES for a one-on-one session in the following weeks, but Jane seems reluctant.
“You want me to actually come here?” she asks, before standing and slowly digging her phone from her handbag to look at the calendar.
TIES has found that these individual parent sessions are critical to the family’s success, even though they fall outside the scope of PCIT.
“Collateral contact with the parents is extremely necessary,” Litvinov said. “Outside the room, you want to have time to process some of those adoption issues and trigger areas that are coming up for the parents.”
Even though she’s put the date in her calendar, it is unclear whether Jane will commit to battling Los Angeles traffic and her depression to attend the additional session. Emma hops a few steps ahead of her mom, and their words become inaudible as they move away from the microphone inside the playroom.
*Names have been changed.