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By Pamela Lowell, MSW, LICSW, BCD

Adoption, Foster Care and Cognitive Behavior Therapy
Inability to manage strong feelings can cause foster and adopted children and teens to act out in inappropriate ways. Cognitive Behavioral Therapy may help these children gain control of their behavior.

Obviously, many of the kids who come to us have experienced multiple loss and trauma. That's how they come in the door. One reason they display difficult behaviors is because certain memories can be re-triggered from a circumstance that reminds them of that original loss. They may not even be conscious of what that memory is, but it brings up similar feelings.

As a family therapist, one of the best ways I know to work with problem behaviors is through Cognitive Behavioral Therapy. Basically this means that feelings trigger thoughts, and those thoughts influence behaviors. We can't control our feelings, nor should we try (because feelings are not good or bad, they just are) but we can control the meaning we assign to our feelings. And by getting a handle on our thoughts, we can manage our behaviors.

After a particularly "difficult" incident you might try asking them questions to help process the event in a different way:

What were you FEELING before you acted out? Mad? Jealous? Scared? Frustrated? What signals were you getting from your body that you were feeling that way? Heart beating fast? Clenched fist?
Was there another time you may have felt that way?
Helping them make the connection to when they had to leave their birth family or when a birth family member disappointed them--or even questions about birth family, missing siblings etc.

What THOUGHT was connected to the feeling? OR What were you saying to yourself at the time? Hitting makes me feel better? Lying will get me out of this situation? There was a thought there, help them find it.

What "BEHAVIOR" was connected to the thought? What did you do? Actually hit the person? Throw something? Scream? Did it get you what you wanted?
If not what could you have told yourself about that feeling to change your behavior and not get you into trouble? In other words what would be a more positive thing for you to think?

For example I once worked with a foster teen who would throw things when she got upset. She told me, "I was angry. (Feeling) My heart was beating fast. I have to throw things--it calms me down. (Thought)"
But the last time she was angry she threw her mp3 player against the wall!(Behavior) It was not an effective way of dealing with her emotions--she lost something valuable to her and was grounded for a week. She also knew she'd have to face adverse consequences from her foster parents and/or the school if she continued to throw things when angry.
She was able to connect this loss to original feelings about losing so many things that were important to her in her life: family, schools, friends, having to move from place to place.

I asked her if another thought might be more helpful when she was feeling angry: "When my heart is beating fast I know I'm getting angry. If I throw something I'm going to get in trouble. What else can I do?"

We came up with a list of behaviors (at least 10) that she could do instead of throwing things that might actually calm her down and not get her in trouble (like listen to music, shoot baskets, tell someone how she feels, do some deep breathing, distract herself, etc.). She knows she can't control whether or not she gets angry, but now she has some tools to deal with that strong emotion.

When any of us behave irrationally or explosively, we are letting our emotions control us--instead of being in control of our emotions. Since teenagers usually resist anybody or any "thing" controlling them, they really relate to this concept. We can also remind them about past times when they did a good job of controlling their emotions. There are circumstances where they probably wouldn't act that way (like in front of a boy or girl they are trying to impress!)

All of us have trouble at times managing our emotions. But we can learn how to control our thoughts and our behavior-it might take a little work, but in the end it will definitely get us more of what we want. That's an offer many kids (and adults) find difficult to refuse.

Pamela Lowell is a social worker and national presenter in the area of ambivalence and permanency issues for foster and adopted teens. She recently published the award-winning children's novel Returnable Girl, about a teen in foster care who lies, steals and throws things when she's upset.

Last week in my counseling office, it happened again. “That was good, what you just said,” replied the mother of a teenage patient, wiping away a tear. The father nodded. “You could use that in one of your books someday.” His fifteen-year-old daughter, smiled at me, a bit awkwardly.
I must admit, she wasn’t the only one who was feeling squeamish. I’m only gradually getting accustomed to the overlapping of my author persona with my “day-job” as a therapist. It still seems strange when patients seek me out because they’ve read one of my young adult novels or visited my author website—as if writing had somehow made me better equipped to help them. If anything, I think the reverse is true. Twenty-five years of listening to young people’s stories has probably served to make me a better writer, especially since I specialize in dealing with adolescents and trauma.
Oh, and the drama-filled stories they tell me!
Like the girl I treated from a local high school who had taken a picture of a part of her anatomy (with her cell phone) and sent it to a boy (just because he’d asked her to.) Can you guess what happened next? This boy, of course, texted it--to half the school! Laurie Halse Anderson’s Twisted anyone? Ironically, this girl was more traumatized by the fact that (because of this incident) the school instituted a policy prohibiting student use of cell-phones--It’s your fault we can’t text anymore--than the fact that so many others had seen the photo.
From my vantage point, trauma among teenagers is on the rise, and many young adult novels seem to reflect that trend. One only needs to look at Boy Toy, Twisted, Right Behind You, Breathing Underwater, and The Burn Journals, to name a few. In real life, from being the middle-school victim of a scathing MySpace attack to forced sexual intercourse and dating stalking/violence, the landscape of Teen World has changed drastically from the one that many of us grew up in--or can imagine. For example, in the small, upscale community where I live, no less than four young teens have died from alcohol-related accidents (in as many years) wreaking havoc on the lives of their families and surviving friends.
I believe that those of us who work with teens--and who introduce them to films or literature or discussions which may contain trauma triggers--need to be educated as to what a trauma response might look like when it occurs in a young person, and how to be most effective in helping them cope and/or eventually seek treatment.
First off, a brief definition: trauma is an experience that is “emotionally painful, distressful, or shocking and which may result in lasting mental and physical effects. It involves the creation of emotional memories about the distressful event that are stored in structures deep within the brain.”
There are evolutionary reasons why and how we store traumatic memories with all of those accompanying smells, sounds, and visual cues. Imagine you are a teen in pre-historic times, out on a “date” near a pretty pond, when suddenly your date is attacked by a saber-toothed tiger! For the survival of your species, it would behoove you to remember not only the gruesome details of how your date expired, but also the location of the pond, the color of the sky, and the smell of the wildflowers nearby. We always store sensory images of trauma, which means that sometimes a seemingly innocuous, unrelated experience can trigger these memories with the emotional punch of the actual event.
This is why a teenager who was molested by her step-father might suddenly turn red and begin shaking during a class discussion of the novel ,Speak. It is why the adopted teen who had been pregnant, but had a secret abortion, might break down sobbing after viewing the movie, ,i>Juno.
The details don’t have to be the same—but the emotional climate may be way too familiar for your tender and vulnerable teen.
Unresolved trauma can create great difficulties in school with memory and learning problems, risky social behaviors, and at home with sleep difficulties and irritable relationships--but there is hope. Sometimes just a few sessions of counseling (cognitive behavioral or EMDR and other advanced techniques) as soon as possible after the actual event, can avoid a young mind’s escape into drugs and alcohol or long term mental health issues down the road.

How do you tell the difference from normal teenage angst from more serious, needing treatment-type trauma? What are the tell-tale signs?

As in the example above, when faced with people, situations, places or things that remind them of traumatic event, teens may re-experience intense and disturbing feelings tied to the original trauma. Their heart may pound or they may freeze in their tracks. They may get dizzy or nauseous, become guilty or ashamed, or feel as if they are in a dream or outside their bodies. It may appear as if they are spacing out. They might think they are going crazy and start to cry.

How can you help when you suspect there is more trauma than drama?

OBSERVE: Ask the teen, “You seem upset. Is there any way I can help?”
This empowers your young adult to ask for what they might need. Even if you might suspect what they are reacting to--don’t offer suggestions or make interpretations. And please don’t say things like, “You’re gonna be okay, right?” If they are exhibiting signs of stress, they are definitely not okay.
COMFORT: Ask them to breathe deeply, and remind them that they are in a safe place. Teens can learn to overcome powerful emotional responses by distinguishing between past and present events. Invite them to remove themselves from the triggering situation but don’t send them alone. If it’s a teaching situation and you can’t leave the room, have another student accompany them to guidance or the nurse or student assistance counselor. If the triggering situation occurs outside a school setting, like at a library discussion group, offer to call a responsible adult.
REFER: As a professional working on the “front lines” with traumatized teens, you have the opportunity to make a real difference in their lives. If the teen happens to “spill” to you, it’s important to tell them that you won’t share the details about what they’ve told you (keeping their confidence) but that you absolutely must share your concerns with another adult. When this happens in my therapy office, I usually say, “What you’ve told me is very disturbing. Would you like to share it with your parents--or would you prefer that I told them?” You should (of course) ask them who they might feel comfortable getting that information. Many times their parents may have noticed that there is a problem, but they are hoping their teen will work it out on their own. When parents hear concerns from another professional, it can be just the nudge they need to get their child the help they need and deserve.
Cognitive behavioral therapy 101: Thoughts influence feelings. Feelings influence behavior. This means basically that the “story” we tell ourselves about a traumatic event can have life-changing ramifications in how we “feel” about it, and how we “behave” in the future. For example, if the girl who texted those racy photos didn’t get treatment, she might tell herself, hundreds of times, “I am bad.” She might then begin to “feel” anxious, sad or depressed, and possibly display maladaptive “behaviors” (drugs/alcohol, other sexual acting out, etc.) in order to support that cognition. That’s why it’s important that she gets help quickly, before those negative “cognitions” take hold. There are many new, well-researched trauma treatments which incorporate body-mind healing--and certified professionals who want to help.
In addition to trauma therapy, I always ask teens about self-care.
Exercising, unplugging from electronics after a certain hour, journaling (not online, please!) can all become part of a healthy daily regimen on the road to healing. Engaging themselves with a good book, (perhaps recommended by their friendly neighborhood librarian, hint, hint) is also a wonderful self-care tool. That said, you might not want to assume that your teen will be “stoked” to read about others in the same boat. Some may, but others might prefer quite the opposite—please, let them lead you.
Ironically, when sitting with teens, I’m often reminded of my own painful traumas from high school—we’ve all got them, right? Still, it has been an honor and privilege to listen to so many of their stories throughout the years. I continue to be blown-away by their courage and honesty, humor and optimism in the face of significant challenge. Translating emotional trauma and overcoming adversity into a universal experience is one of the primary reasons why I write for young adults. But whether I’m doing therapy or writing novels, I’m convinced that sharing stories is one of the truly time-tested ways in which we all connect and heal.

Pamela Lowell is the author of the award-winning Returnable Girl, (Voya Top Shelf in 2007, International Reading Association Young Adults’ Choices 2008, and ALA Quick Pick).
Spotting for Nellie (Marshall Cavendish: Spring) is her newest novel about a teen gymnast who suffers a traumatic brain injury after her older sister crashes their car on the way home from a drinking party.
Pamela is a licensed, independent clinical social worker who enjoys counseling young adults and their families. She has presented at national conferences on teens and trauma and can be reached via her website at www.pamelalowell.com.