Since the notorious case of the return to Russia of a Tennessee mother's adopted son, family after family has been quoted as saying, "We've tried everything. Nothing works. The child is impossibly difficult and we must give up, for our own sake and the sake of our other children." An article in the New York Times a few days ago described how some families simply "boarded" the children at a residential treatment center at a considerable monthly cost rather than have them at home.
There seems to be little doubt that most of those adoptive parents have indeed tried very hard and have thrown their energies into at least one challenging treatment program. Some have tried several methods that demanded major commitments and changes from their ordinary lives. It's not surprising that they feel they've "tried everything".
But have they actually tried anything that was likely to help? With all due respect and sympathy for these families, I'd like to suggest that they may have missed a genuinely helpful approach that is not yet well-known. I am referring to "collaborative problem solving" (CPS), a method proposed by Dr. Ross Greene, author of "The Explosive Child", and recently discussed by Richard Smith in that extremely useful publication, the Brown University Child and Adolescent Behavior Letter.
Before I describe how CPS is done, I want to comment on a most important issue that helps determine how a family chooses and participates in any child mental health intervention. This is the family's attitude or set of beliefs about why children behave as they do--- why they are pleasant and co-operative or irritable, resistant, even assaultive.
There are currently two major sets of beliefs about child behavior in the United States (of course, there are other less common beliefs, but let's concentrate on these two). The first attitude is one connected with behavior modification and operant conditioning methods. It says (as Richard Smith put it) "children do well if they want to". Treatment involves making the child "want to" do well, by associating rewards with desirable behavior, or even by making sure the child cannot get some wanted things without co-operating. In practice, of course, a sensible parent or therapist would not try to use reward to get a child to do things he or she really cannot do, such as overcome physical handicaps. However, it may be all too easy to assume that a child actually can control tantrums or talk about feelings when this is not true; the recent Zero to Three report showed how often parents are mistaken about how long such abilities take to develop. The belief that "children do well if they want to" is a simple and attractive one, but it may not be accurate.
A second common attitude reflects some popular beliefs and the tenets of many unconventional therapies. Historically, it goes back to pre-Revolutionary times in this country. This attitude involves the belief that children naturally want to lie, steal, and exploit and manipulate their parents, and that they are potentially dangerous to others. These serious failings are overcome only by a forceful assertion of authority by adults. In other words, this attitude holds that "children want to be bad" and that it is the job of parents to show children that there will be painful consequences for them if they do what they want. If parents or other caregivers have not managed this, adoptive parents have to work hard at the task.
Collaborative problem solving (CPS) offers parents an alternative attitude that contradicts both of the beliefs I've described, but is especially contrary to the view that children want to defy adult authority. The CPS approach can be summarized as "children do well if they can". The job of parents and therapists, then, is to identify factors in the child and the environment that make it hard for the child to do well, and to work co-operatively with the child to eliminate or improve these factors.
An important aspect of CPS is that it avoids paying much attention to diagnostic categories such as Bipolar Disorder or Reactive Attachment Disorder, and instead seeks the individual factors that cause trouble for a given child. For example, does the child have trouble using or processing language (as one of the Russian adoptees on the recent "Nightline" program appeared to do)? Does the child have difficulty when in crowded places or where there is a lot of excitement and activity? Do problems emerge when there are transitions--- from play to bedtime, for instance, or every morning when getting up? Recognizing these specific problems is a step in understanding what a child can or cannot do, and provides a foundation for treatment of the family.
One of the challenges of bringing a family into CPS is the need to help them adopt the attitude that the child will "do well if he can". It is difficult to do this work with parents (or children!) who believe that a child behaves poorly because he does not really want to do well, or that children actually want to behave badly and must be coerced into doing otherwise.
Once the family accepts the idea of "doing well if he can", they need help in defining what factors (like the ones noted earlier) are preventing the child from doing well. The next step is to discuss what CPS advocates call "plans A, B, and C".
Plan A is the strategy already used by most parents of difficult children--- yelling, punishing, and coercion. Plan A generally leads to tantrums or precipitates other forms of difficult child behavior like the hour-long "rages" parents often mention.
CPS tries to reduce the use of Plan A by offering other plans with better outcomes. Plan C involves making decisions to reduce the number of situations which are too difficult for a child to cope with at this point. For example, if parties always lead to undesirable behavior, the child does not go to parties for the time being. Even a "must do" like brushing teeth may be omitted if it seems to be beyond what the child is now capable of handling.
Plan B comes in when Plan A behavior has been reduced and Plan C is in place. Plan B is the essence of CPS, and it involves having parents and children work together under the guidance of the therapist to decide how to solve a problem and enable the child to do better. As Richard Smith points out, this can be very difficult, in part because at the beginning of a session there can be no clear idea of how the problem may be solved; this situation is very much in contradiction to the usual parental belief that parents know how to solve a problem and must convince their child or make him do things their way. Interestingly, CPS advocates suggest that a child needs only about a 3-year-old intelligence level to be able to participate in Plan B work.
Several research reports support the effectiveness of CPS with irritable and aggressive children. Of course, this kind of research is difficult to do well, and more is needed. In addition, parents are likely to have trouble finding therapists who are versed in this method unless they live in one of a few large cities. Nevertheless, it is clear that CPS has real promise, and parents who have not tried this approach have not "tried everything", though they may feel that they must have.
