This HBO documentary explores the struggle of three moms who are trying to find mental health services for their aggressive sons.
A Dangerous Son tells the story of families with sons who have disorders that lead to explosive, violent behaviors. These kids are a danger to their families and themselves – but there are few options for mental health services. The documentary doesn’t go into the diagnoses of the children but does mention the autism spectrum, intellectual disability, and schizoaffective disorder.
While our children may have different diagnoses, the issues are the same for every parent struggling with a child who has violent behaviors. The themes are eerily familiar:
The documentary is headlined by Liza Long who wrote the viral blog post, “I am Adam Lanza’s Mother,” in the aftermath of the Sandy Hook school shooting. If you haven’t read it, here’s an excerpt:
I live with a son who is mentally ill. I love my son. But he terrifies me…In the wake of another horrific national tragedy [Sandy Hook], it’s easy to talk about guns. But it’s time to talk about mental illness.
The lack of mental health treatment for kids with a propensity for violence is a national tragedy. It’s impacted Liza Long’s family and my own. And in some cases it spills out into our schools and communities. A Dangerous Son is a well made, compelling documentary that helps raise awareness around the difficulties of parenting a child who has violent behavior and the struggle to find help.
Have you seen it? Drop a comment below to share your thoughts.
Imagine identifying a toxin so potent it could rewire a child’s brain and erode his immune system. A substance that, in high doses, tripled the risk of heart disease and lung cancer and reduced life expectancy by 20 years.
And then realizing that tens of millions of American children had been exposed.
Dr. Nadine Burke Harris, California’s newly appointed surgeon general, will tell you this is not a hypothetical scenario. She is a leading voice in a movement trying to transform our understanding of how the traumatic experiences that affect so many American children can trigger serious physical and mental illness.
The movement draws on decades of research that has found that children who endure sustained stresses in their day-to-day lives — think sexual abuse, emotional neglect, a mother’s mental illness, a father’s alcoholism — undergo biochemical changes to their brains and bodies that can dramatically increase their risk of developing serious health problems, including heart disease, lung cancer, asthma and depression.
“[Nadine] has probably single-handedly done more to elevate this issue than anyone else,” said Dr. Mona Hanna-Attisha, the pediatrician known for documenting the rise in children’s blood lead levels in Flint, Mich., after the city switched its water supply.
With Burke Harris’ selection as the state’s first surgeon general, California is poised to become a vanguard for the nation in embracing the research that traces adverse childhood experiences, or ACEs, to the later onset of physical and mental illness. In pockets across the country, it’s increasingly common for schools and correctional systems to train staff on how academic and behavioral problems can be rooted in childhood trauma. Burke Harris envisions a statewide approach whereby screening for traumatic stress is as routine for pediatricians as screening for hearing or vision, and children with high ACEs scores have access to services that can build resilience and help their young bodies reset and thrive.
As California’s surgeon general, she will have a powerful bully pulpit — and the firm backing of a new administration with deep pockets. In his first weeks in office, newly elected Gov. Gavin Newsom has made clear he intends to devote significant resources to early childhood development. He has named several recognized experts in child welfare, along with Burke Harris, to top posts, and is promoting child-centric policies that include extended family leave for new parents, home nursing visits for new families and universal preschool. In his first state budget proposal, released last month, Newsom called out ACEs by name and committed $105 million to boost trauma and developmental screenings for children.
“It should be no surprise to anyone that I’m going to be focusing on ACEs and toxic stress,” Burke Harris said in a phone interview just days into the new job. “I think my selection is a reflection of where that issue fits in the administration’s priorities.”
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A Game-Changing Study
Adversity is the sort of thing we intuitively understand, at least to some extent. Having a parent who struggles with addiction or mental illness is hard on kids, as is growing up in a neighborhood marked by poverty, gun violence or drug abuse.
A 1990s study laid the groundwork, however, for an understanding of adversity that suggests it poses a pervasive threat to public health.
During interviews with patients at a Kaiser Permanente obesity clinic in Southern California, Dr. Vince Felitti was shocked at how many said they had been sexually abused as children. He wondered if the experiences could be connected. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)
As head of the Department of Preventive Medicine at Kaiser Permanente in San Diego, he had access to a huge pool of patients to try to find out. Together with the Centers for Disease Control and Prevention, he surveyed more than 17,000 adult patients about 10 areas of childhood adversity. Among them: Did a parent or other adult in your household physically abuse you? Emotionally abuse you? Sexually abuse you? Go to prison? Was your mother regularly hit? Did you often go hungry? Were your parents divorced? The researchers scored each patient, assigning a point for each yes, and matched up the responses with patients’ medical records.
What they found was striking. Almost two-thirds of participants reported experiencing at least one kind of adversity, and 13 percent — about 1 in 8 — said they had experienced four or more. Those who reported experiencing high doses of trauma as children were far more likely to have serious health problems as adults, including heart disease, stroke, cancer and diabetes. And the higher their ACEs score, the worse their health was likely to be.
This extended to mental health, as well: Adults who reported experiencing four or more ACEs were 4.6 times as likely to have clinical depression and 12 times as likely to have attempted suicide.
In the 20 years since, scientists have built on the research, replicating the findings and digging into the “why.” In the simplest terms, traumatic events trigger surges in cortisol, the “stress” hormone. When those surges go unchecked for sustained periods, they can disrupt a child’s brain development, damage the cardiovascular system and cause chronic inflammation that messes with the body’s immune system.
And where children really get into trouble is when they also are missing the best-known antidote to adversity: a nurturing and trustworthy caregiver. Without that positive stimulation, children can end up with an overdeveloped threat response and a diminished ability to control impulses or make good decisions. Children with high ACEs scores are more likely to develop attention deficit hyperactivity disorder, known as ADHD, and cognitive impairments that can make school a struggle. They are more likely to grow into adults who drink to excess, are violent or are victims of violence.
The research is compelling, because it has the potential to explain so many intractable health problems. What if some portion of Generation ADHD really has PTSD? What if obesity and hypertension are disorders with roots in childhood experiences, and not just what we eat for dinner?
‘What Happens To You Matters’
Until now, Burke Harris’ professional epicenter has been Bayview-Hunters Point in San Francisco. It’s a vibrant community with a history of activism, but also deeply impoverished, and blighted by pollution and violence. It was there that Burke Harris, at her pediatric clinic, noticed that many of her young patients with serious medical conditions also had experienced profound trauma. And patients who had experienced serious adversity were 32 times more likely to be diagnosed with learning and behavioral problems than kids who had not.
When a colleague introduced her to the ACEs study, she saw her patients written between its lines. Though these problems might be concentrated in Bayview, they certainly weren’t confined there. This was a health crisis transcending race, class and ZIP code.
In the years since, Burke Harris has worked to advance ACEs science though her work at the clinic and her nonprofit research institute, the Center for Youth Wellness. She regularly travels the country to train fellow pediatricians in trauma screening and treatment. She has written an acclaimed book on the issue, “The Deepest Well,” and her TED talk on the topic has been viewed nearly 5 million times online.
Now, she’ll be directing her singular focus back on California.
She plans to start with a statewide tour to hear from doctors and other health leaders about barriers to increasing pediatric screening and care. She’ll also be talking about the science of ACEs. “It’s Public Health 101 that raising awareness is a critical form of primary prevention,” she said.
But even with the funding included in Newsom’s budget, there are challenges to standardizing trauma screening. For one: In medicine, it’s common practice that you screen only for what you can treat. Many doctors — even those persuaded by research on adversity — have raised concerns about the lack of established protocols for treating childhood trauma. What can a pediatrician, with her 15-minute time slots and extensive to-do list, do about the ills of an absent parent, or a neighborhood riddled with gun violence?
In general, experts working on the issue say a critical ingredient in helping kids heal is ensuring they find and develop healthy relationships.
“All of us want to feel seen, heard, understood and supported,” said Alicia Lieberman, a researcher at the University of California-San Francisco who specializes in early childhood trauma. Involving parents is an essential aspect of treatment, particularly because so many have experienced trauma themselves. “It has to start with an acknowledgment that what happens to you matters.”
Researchers have found early success in seemingly simple interventions: Therapists coaching parents by filming and playing back positive interactions with their child. Therapists working with teachers on how to support their students. Key to success, said Pat Levitt, chief scientific officer at Children’s Hospital Los Angeles, are quality programs that start early and recognize the role of relationships.
At her clinic, Burke Harris coordinates with a team that wraps a child in care, treating mind and body. When a patient scores high on the adversity scale, she can send them down the hall to a therapist; connect them with classes on meditation, nutrition and exercise; involve the family in counseling; and aggressively monitor for and treat any physical manifestations.
Most clinics aren’t set up for this staff-intensive approach.
Dr. Andria Ruth, a pediatrician with the Santa Barbara Neighborhood Clinics in California, is among those researching how to “treat” adversity within a more traditional doctor’s office. Her research team is randomly assigning patients who screen positive for trauma into one of three groups. One group is assigned a navigator who connects the family to services for basic needs, such as food and housing. A second group also sees a behavioral health therapist at their child wellness visits. The third group receives both those services, and gets home family visits from therapists.
Ruth has a healthy skepticism about what’s possible, but she and her colleagues are convinced childhood trauma does pose a potent health threat: None of them felt comfortable including a control group that wouldn’t receive any services.
In the big picture, these experts say, addressing the fallout of traumatic stress will require a broader paradigm shift, to a system that recognizes that bad behavior can be a physical symptom rather than a moral failing. Gov. Newsom has signaled a move in that direction: In January, he said he would transfer the Division of Juvenile Justice out of the Department of Corrections, which runs the state’s prison system, and into the Health and Human Services Agency.
Garnering that kind of official backing is a powerful boost, said Jason Gortney, director of innovation at the Children’s Home Society of Washington, that state’s oldest and largest nonprofit dedicated to child welfare. His organization has lots of programs with promising results, he said, but connecting them to state agencies that aren’t used to working together is a challenge.
With Burke Harris crusading from the surgeon general post, Gortney said, he and fellow advocates across the country are hoping California can provide a beacon.
“Maybe California can show some of the other states how to do this,” he said.
Caleb, 11, was thin with blond hair, glasses, and a big smile where crooked teeth jockeyed for space. He and his brother, Elijah, were adopted by Martin and Dena Lishing when Elijah was a toddler and Caleb was a baby. Their young birth mother struggled from addiction.
Born a preemie at 24-weeks-old and weighing only 1 pound, Caleb beat the odds. His 5th grade teachers remember him as shy, inquisitive and loving. He wore cowboy boots to school every day. He was fascinated by all things Titanic. A classmate says, “He was really funny. He always had jokes and puns to tell.”
It was a warm, overcast evening on April 23, 2018–Caleb was asleep in his bed. An adult babysitter was in a nearby room. Meanwhile, 13-year-old Elijah dismantled their grandfather’s locked gun cabinet to access a .357 Magnum. Caleb was sleeping on his stomach when Elijah shot him in the back, killing him.
This tragedy was the first murder in the small, sleepy town of Streetsboro, Ohio in 20 years. But it wasn’t the first time police were called to the Lishing home on Alden Drive.
Mental health interventions, too late
Over the years, the family had attempted – unsuccessfully – to get mental health treatment for Elijah although details are not public. Reports indicated Elijah tried to commit suicide twice. In 2017, Elijah was charged with indecent exposure on the school bus. In 2018, his stepmother called police because he became “unruly.” When he told officers he was thinking of harming himself, they transported him to a local behavioral health center for evaluation.
Only four days later, Elijah shot and killed his little brother Caleb. Police have not disclosed Elijah’s motive but say it was premeditated.
Psychologist Dr. Amy Thomas testified at the sentencing hearing that Elijah suffered early childhood abuse. Elijah claims, in addition to neglect from his birth mother, he was subsequently abused in the Lishing home. He details harsh punishments from a young age and says his adopted mother was more devoted to premature Caleb than to him. The Lishing couple also divorced several years after the adoption.
Thomas diagnosed him with reactive attachment disorder (RAD), also called developmental trauma disorder (DTD). This often occurs when a child experiences chronic abuse or neglect before the age of 5. A child with DTD has disrupted brain development and, if not provided early and highly-specialized intervention, can suffer long-term and devastating impacts. They have difficulty forming healthy attachments with caregivers and others which can lead to familial, social, educational and legal issues. Dr. Thomas also diagnosed Elijah with post-traumatic stress disorder and conduct disorder, both common diagnoses for children with DTD.
Elijah’s situation is even more complex than DTD alone, however. Dr. Thomas testified that Elijah also suffers from paranoia and stated that a previous clinician had diagnosed him with schizophrenia. Reflecting on the time of the murder, Elijah told the court, “I was living inside my head, unable to determine the difference between imagination and reality.” This points to serious mental illness in addition to complex DTD.
The worrisome correlation of complex developmental trauma and mental illness
Dr. John Alston, psychiatrist for the Institute for Attachment and Child Development, found a strong correlation between complex DTD and co-morbid mental illness. In his studies, Dr. Alston recognized that adults who abuse or neglect their children often do so as a result of a mental illness. Thus, their children may suffer the unfortunate combination of both the nature (genetics) and nurture (attachment) consequences.
And when children with complex DTD inherit a mental illness, it is often in a profound way according to Dr. Alston. He gives the analogy of more commonly-known childhood health issues. “You never hear of symptoms of childhood diabetes in a mild form, you never hear of childhood asthma in a mild form. They are always inherited in a severe or profound form and therefore the earlier the onset, the more severe the disorder, the more intensive the treatment needs to be,” said Dr. Alston. “It is exactly the same when we are talking about mental health disorders.”
Elijah told the court, “I was living inside my head, unable to determine the difference between imagination and reality.” This points to serious mental illness in addition to complex DTD.
Forrest Lien, Director of the Institute for Attachment and Child Development, is adamant that not all children with developmental trauma are dangerous. Rather, it is often the unfortunate combination of specific and severe disorders. “Developmental trauma disorder alone does not deem a child dangerous. Furthermore, not all children with DTD have a mental illness. Yet, some do,” Lien says. “Children with complex developmental trauma often feel angry and can lack empathy. When you combine a child who feels slighted and vengeful with a misdiagnosed or poorly-treated severe bipolar disorder with psychotic features, it can be dangerous.”
Neuroscience is an emerging science and this link between early trauma and mental illness is not well known. However, given the potential for sometimes dangerous antisocial behavior, it is critical that clinicians still give careful consideration to these correlations. It is vital, Dr. Alston says, to differentiate the impact of severe trauma from potential mental illness symptoms in order to properly diagnose and treat the whole child.
The case for better mental health support
Unfortunately, Elijah’s developmental trauma and co-morbid disorders were not accurately diagnosed until after he was incarcerated—not in time to prevent this horrific incident. He did not receive appropriate treatment and the costs to his family and himself have been enormous.
Martin and Dena are heartbroken having suffered the loss of their children. Innocent 11-year-old Caleb’s life has been cut short. And they must now grapple with the incarceration of their other son.
“When you combine a child who feels vengeful and slighted with a misdiagnosed or poorly-treated severe bipolar disorder or schizophrenia with psychotic audio and visual hallucinations, it can be dangerous,” said Institute for Attachment and Child Developmental Executive Director Forrest Lien.
Elijah, now 13, is a convicted murderer facing a lifetime of struggles. He has been sentenced to juvenile detention until he turns 21 and at that time his case will be reevaluated with the potential for adult detention time. According to the Record Courier, “Judge Robert Berger said that despite abuse the boy suffered as a child, it did not excuse shooting and killing his brother.”
Perhaps with earlier diagnosis and interventions, Elijah wouldn’t be sitting in a prison cell today. Caleb might be running around the playground instead of being memorialized by the Titanic-shaped play fort the community is erecting in his memory.
Published originally by IACD. Updated 1/28/2019 after sentencing.
Justin Taylor Bean, removed from his abusive birth parents as a toddler, spent the next two decades in psychiatric hospitals and more than 40 residential facilities.
Over the years, his physical and verbal aggression increased despite treatment and medication. Then, at the age of 22, Justin strangled to death a fellow group home resident.
During his sentencing last month, District Attorney Laura Thomas argued almost sympathetically that Justin “did not have a chance — it was all over for him at age 2.” She then asked that he be sentenced to a life behind bars, which he was.
“There’s not a miraculous cure,” Thomas said. “The public needs to be protected from him forever.”
Many will be outraged by this story, but few will understand how something like this happens. After all, all the warning signs were there. Doesn’t that mean this could have been prevented?
Sadly, it’s not that simple.
More than a million children each year experience early childhood trauma, most often due to abuse and neglect. “Developmental trauma,” a term coined by leading expert Dr. Bessel van der Kolk, affects a child’s brain development. The impact can be devastating, including severe attachment and behavioral issues. These traumatized children need comprehensive, specialized professional intervention and treatment – treatment that’s expensive and not available in most areas.
Unfortunately, I know all too well just how true this is. My adopted son, Devon, has also attempted to seriously harm fellow residents in group homes – more than once. Like Justin, Devon has a diagnosis of reactive attachment disorder and has a similar treatment history. My son could easily have killed someone, he’s just been small enough that staff can control him.
He’s received medication and thousands of hours of therapy. He’s only become more violent and dangerous. Unable to safely live at home, he’s been in and out of psychiatric residential treatment facilities for years. All I can do is helplessly watch as he careens toward adulthood, an angry and violent young man.
What’s clear from Devon and Justin’s stories is that our mental health system does not yet know how to effectively treat children with the most severe developmental trauma. Residential treatment facilities, often the only available choice, are virtual incubators for violence, and many children leave more dangerous than they went in. And far too many end up institutionalized or incarcerated.
As a society, we take these already broken and vulnerable children, and like a gruesome medieval torture press, crush their hope for a good future. We perpetuate their trauma by piling on with broken systems that exacerbate the very problems they try to address: foster care, family court, health care, mental health services and juvenile justice, to name a few.
Further, our communities don’t understand developmental trauma and underestimate its impact. And so, schools, unwitting parents, therapists and social groups pile on too. Under this pressing weight, what hope is there for these children?
The vast majority of people with mental health disorders do not go on to commit murder. But given our apathetic and broken mental health system, developmental trauma can be its own life sentence for youth in the child welfare system. It negatively affects all areas of life – relational, legal, educational and financial. A few victims, like Justin, go on to commit violent crimes.
How many lives have to be destroyed? Isn’t it time to recognize developmental trauma as the unsolved challenge it is, and prioritize funding research, prevention and treatment? Until we do, too many broken children will continue to grow into broken adults and we will continue to see tragedies like the murder committed by Justin.
Today my son’s therapist apologized to me. (Go ahead, take a moment to pick yourself up off the floor, then keep reading…) If you’re the parent of a child diagnosed with reactive attachment disorder (RAD) you know just how significant this is.
As parents of children with developmental trauma, one of our biggest pain points is dealing with therapists who don’t “get it.” They blame us, are manipulated by our kids, and offer our families little practical help. At best they’re ineffective, at worst they cause enormous damage.
My son’s current therapist, we’ll call her Amy, has made the classic blunders we’re all so familiar with.
She tells my son all he really needs is my love, excusing him from responsibility.
She praises his cunning circumvention of rules as “trying really, really hard.”
She disagrees with me openly and emphatically in front of my son.
She makes me the “bad guy” in therapy sessions.
She prioritizes her relationship with my son over mine.
Can I get a show of hands? I sure know most of us are struggling with these very same issues.
But today something unexpected happened. I confronted Amy and she acknowledged she could have handled things better and apologized. We then worked together to come up with a reasonable path forward. I very nearly fell off my chair.
In retrospect, here are a few things that may have contributed to this success:
I was confident, not defensive. When we act defensively, therapists are quick to write us off as unreasonable, close minded and pissed off. It’s important to be in a place where we know our rights and can speak as confidently and unemotionally as we might in a business presentation.
I didn’t get personal. We’ve all been offended and hurt by therapists and it’s easy to become wrapped up in those feelings. But when we do, our confrontation goes off the rails. In the end, the conversation shouldn’t be about our feelings at all. It should be about the needs of our child.
I focused on my child. Don’t talk about what the therapist has done to you, or how they have made you feel. Keep the focus on what’s best for your child. My child needs to be safe. My child needs to build a strong secure relationship with me. These are specific things you and the therapist can agree on.
I was specific and kept it simple. If you walk into these conversation with a laundry list of problems, it’s far too easy to get lost in the weeds. Pick one specific issue that highlights the underlying problems to focus on. Make it specific, actionable, and simple. Pick something as objective as possible.
I was reasonable.What can you expect out of a confrontation? You’re not going to change the therapist’s style or philosophy. You’re unlikely to educate them on RAD and DTD, although you might crack open the door for that. What you should be able to do, is come to an understanding and agree to some ground rules.
It sure felt good when Amy apologized to me, but that mattered far less than the action plan we put into place. With a common goal established we agreed to:
Meet prior to family therapy sessions to agree on how news will be delivered to my son and how to approach what will be discussed in the session.
If a topic comes up that we need a sidebar on, before discussing in front of my son, I’ll use a code word and she’ll put off that topic until after we’ve had a time to talk privately.
Every therapist, family, and child is different. Some therapists are easier to work with than others and this isn’t a one-size-fits all formula for every situation. Still, I hope reflecting on my experience may provide a useful starting point as you work hard to advocate for your kids and help them get the therapy they need.
I stand in the bathroom stall of the courthouse, texting a friend. “I can’t do this,” I write and lean my head against the cold partition of the stall.
“You’ve got this,” she replies. “Breathe, Honey.”
I hear the restroom door open and a singsong voice I recognize as my daughter, Debbie, quietly calls my name. I quickly pull my feet up, trying to be invisible. “I know you’re in here, you stupid bitch. Come out, come out, where ever you are.”
My breath halts and my pulse pounds in my ears. Be still, be quiet, I think. Maybe she will go away.
Footsteps approach as door after door of the stalls bang open. I quake in fear as the steps come nearer until I see her shoes in front of my door.
“You can’t hide forever,” Deb says in a lilting, singsong voice. She quickly tells me how plans to murder me and what she will do with my body before setting it and my home on fire. She reminds me that she has had months to perfect her plan, while in juvenile detention, without my interference.
I don’t respond.
Tiring of her game, Deb’s voice acquires the hard edge I’ve come to associate with rage. “Get out here, you bitch. I hate you. I want to see you scream as you die. Your precious boy will die, you will all die.” I cower behind the door as her diatribe continues; the words increasingly vulgar.
Suddenly the door into the hall opens and a new voice speaks. “Deb, are you in here?”
I hear Deb whisper, “Shit.” Then she begins to sob.
“Baby, what’s wrong? What happened?” I recognize the newcomer as Deb’s caseworker.
Still sobbing, Deb says, “I saw Mommy come in here. I just wanted a hug. She hates me.” She wails and sobs as though her world has just ended. “Why doesn’t she love me, Miss C?”
Debbie is only 14. Debbie has Conduct Disorder.
What is Conduct Disorder?
The DSM-5 (the manual used by mental health professionals to make diagnoses) defines Conduct Disorder (CD) as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.”
Children with Conduct Disorder (CD) may exhibit behaviors such as:
bullying, threatening, or intimidating others
initiates physical or verbal altercations
physically or verbally cruel to others
physically cruel to animals
steals
forces someone into sexual activity or is sexually aggressive
superficial charm/has a public and private demeanor
lack of fear
Recent scientific studies indicate CD is in part due to abnormal brain activity, as well as an under development of the amygdala and prefrontal cortex. The amygdala is known to be responsible for controlling aggression as well as the perception of emotions. The prefrontal cortex handles executive functions such as controlling short-sighted or reflexive behaviors in order to plan long-term goals, make informed decisions, and exhibit self-control.
But what does all of this really mean?
In simple terms it means that the child with Conduct Disorder has a brain that is structurally different from that of a neuro-typical child. Because of this difference, the child with CD does not respond to rules, discipline, and societal norms the way a typical child does.
Conduct Disorder is evidenced by some, or all, of the behaviors listed above. The spectrum of behaviors is wide and varies between mild to severe. The tendency to lie, manipulate, and gaslight are strong and seemingly innate behaviors.
Standard parenting techniques are not effective. Discipline, rewards for good behavior, star charts, and other techniques fall short of managing behaviors long- term. Conduct Disorder transcends race, ethnicity, environment, location, and socioeconomic backgrounds. Unlike attachment disorders CD is not always due to trauma, abuse, or neglect. However, many children diagnosed with Reactive Attachment Disorder (RAD) at younger ages are ultimately diagnosed with CD as teenagers. CD can manifest at 2 years old or 15 years old, and any age in between.
There are an estimated 7 million children in the U.S. alone with Conduct Disorder. This translates into approximately 1 in 10 children affected.
For families affected by CD, it can mean very little in terms of treatment. Children with Conduct Disorder do not respond well to traditional talk therapy. In general, these children will use the counselor to further manipulate caregivers. Some go so far as to employ triangulation, in which the counselor becomes the unwitting accomplice of the child to further demoralize caregivers. Medication cannot relieve the symptoms of CD but it may be prescribed for co-morbid diagnoses such as ADHD.
At present there are very few viable inpatient treatment centers for children with Conduct Disorder. Many programs state that CD is treated at their facility, however most apply standard practices toward the treatment of other mental illnesses to CD. This is highly inappropriate and may lead to further issues for both the child and family living with CD.
Often, families feel vilified and become isolated due to the harsh judgment they face. Family and friends lack understanding of what is happening and drift away, unable to provide support for something they seldom witness. Parents beg doctors and mental health professionals for help, only to be mocked and treated with derision. The community, hearing of the child’s disrespect and abusive nature when the police are called, make assumptions about the parents: too lenient, too strict, not enough activities, too many activities, set boundaries, spank him/her, it’s all because of poor parenting, they say. All this does it further isolate families who are living in a constant war zone, created by someone they love and for whom they are legally responsible. Love does not cure Conduct Disorder (CD), nor does being a model family.
If there are no treatment options available, what can be done?
Fortunately, CD is being researched more in recent years. Unfortunately for those living with CD, viable treatment options are still years in the making. The founders of Compass for Conduct Disorder realized the need for community support programs, resources for parents/caregivers, and early childhood detection and intervention.
Compass for Conduct Disorder is a nonprofit organization whose goal is to provide resources, services, and hope for those living with CD. In addition to a parent/caregiver support group, Compass also provides an information and awareness group, parent advocacy, crisis buddies, the Compass Peer Network for professionals to exchange information relating to CD, and an awareness raising campaign. In the planning stages is the Compass Child and Family Support Center, which will be geared toward children ages 2 to 5 showing early signs of Conduct Disorder, and their families.
If you have a child with Conduct Disorder, Compass for Conduct Disorder is a place to find support, resources, and community.
Karen Huff is the mother of four children, one of whom has Conduct Disorder.
She is the President for Compass for Conduct Disorder and an admin for the Compass Cares support group, as well as for the Compass for CD Information and Awareness group.
When Toni and Jim Hoy adopted their son Daniel as a toddler, they did not plan to give him back to the state of Illinois 10 years later.
“Danny was this cute, lovable little blonde-haired, blue-eyed baby,” Jim said. There were times Daniel would reach over, put his hands on Toni’s face and squish her cheeks.
“And he would go, ‘You pretty mom,’” Toni said. “Oh my gosh, he just melted my heart when he would say these very loving, endearing things to me.”
But as Daniel grew older, he began to show signs of serious mental illness that manifested in violent outbursts. When his parents exhausted all other options, they decided to relinquish custody to the state to get Daniel the treatment he needed.
“To this day it’s the most gut-wrenching thing I’ve ever had to do in my life,” Jim said. “But it was the only way we figured we could keep the family safe.”
Across the U.S., children encounter many barriers to mental health treatment, including a shortage of psychiatric beds and coverage denials from insurance companies. In a desperate attempt to get their child treatment, some parents have discovered a last resort workaround: they trade custody for treatment.
Known as a psychiatric lockout, a parent brings a child to a hospital and refuses to pick them up. The child then enters foster care, and the state is obligated to pay for their care.
This happened to Daniel in 2008, and has happened to thousands of other children before him, according to a report from the Government Accountability Office.
Today, despite a 2015 Illinois law that states families should never have to trade custody for mental health treatment, at least four children a month enter state custody this way, according to data obtained by Side Effects.
Out of options
Daniel grew up as the youngest of four children in Ingleside, just north of Chicago. As a baby, he’d been severely neglected — starving and left for dead — and the early trauma Daniel experienced affected his brain development.
At around age 10, his post-traumatic stress disorder manifested in violent outbursts.
“You could almost tell the stories that would describe him like a monster,” Toni said.
“He held knives to people’s throats. He tried putting his fingers and his tongue in the light sockets. He broke almost every door in the house.”
In the car, there were times when he’d reach over and grab the wheel while Toni was driving to try and force the car into oncoming traffic. Other times, he would lash out at his siblings.
“At the same time, he’s a little boy,” she said. “He didn’t want to be that way. He didn’t like being that way.”
Despite Toni and Jim’s efforts to help their son with therapy, the violence escalated. Daniel was hospitalized almost a dozen times over a period of two years.
His doctors said he needed more intensive mental health services than he could get while living at home. He needed 24/7 residential treatment, but both Daniel’s private health insurance, and the secondary Medicaid coverage he received as an adoptee, denied coverage.
So the Hoys applied for a state grant meant for children with severe emotional disorders. They also asked for help from Daniel’s school district, which is supposed to cover a portion of the costs when students need residential care. They were denied both.
“We were told we had to pay out of pocket for it,” Toni said. The treatment could cost up to $150,000 a year, and that was money they didn’t have.
Then, during Daniel’s 11th hospitalization, the Illinois Department of Children and Family Services, or DCFS, gave the Hoys an ultimatum.
“[They] basically said, ‘If you bring him home, we’re going to charge you with child endangerment for failure to protect your other kids,’” Toni said. “‘And if you leave him at the hospital, we’ll charge you with neglect.’”
Out of options, the Hoys chose the latter option as a last-ditch workaround to get treatment.
Once the DCFS steps in to take custody, the agency will place the child in residential treatment and pay for it, said attorney Robert Farley, Jr., who is based in Naperville.
“So you get residential services, but then you’ve given up custody of your child,” he said. “Which is, you know, barbaric. You have to give up your child to get something necessary.”
The Hoys were investigated by DCFS and charged with neglect. They appealed in court and the charge was later amended to a “no-fault dependency,” meaning the child entered state custody at no fault of the parents.
Losing custody meant Toni and Jim could visit Daniel and maintain contact with him, but they could not make decisions regarding his care.
Toni spent months reading up on federal Medicaid law and she learned the state-federal health insurance program is supposed to cover all medically necessary treatments for eligible children.
The Hoys hired a lawyer, and two years after giving Daniel up, they sued the state.
Less than a year later, in 2011, they settled out of court, regained custody of Daniel, who was 15, and got the funding for his care.
Around the same time, Farley decided to take on the lack of access to mental health care on behalf of all Medicaid-eligible children in the state. He filed a class-action lawsuit, claiming Illinois illegally withheld services from children with severe mental health disorders.
“There [are] great federal laws,” Farley said. “But someone’s not out there enforcing them.”
In the lawsuit, Farley cited the state’s own data that shows 18,000 children in Illinois have a severe emotional or behavioral disorder, yet only about 200 of them receive intensive mental health treatment.
In a settlement in January, a judge ruled the state must make reforms to comply with Medicaid law. The state has until October to come up with a plan to ensure all Medicaid-eligible children in the state have access to in-home and community-based mental health services.
A law that didn’t fix the problem
While these legal battles were taking place, lawmakers began their own work to ensure parents no longer have to give up custody to get their children access to mental health services.
In Illinois, six state agencies interact with at-risk children in some form. But Democratic state Rep. Sara Feigenholtz said they operate in silos, which causes many children to slip through the cracks and end up in state custody.
“It’s almost like these there’s a vacuum, and the kids are just being sucked into DCFS,” she said.
Feigenholtz worked to get a bill passed in 2014. The Custody Relinquishment Prevention Act, which became law in 2015, orders those six agencies to work together to help families that are considering a lockout to find care for their child and keep them out of state custody.
So the agencies developed a program together that launched in 2017 — years after the deadline set by the law. It aims to connect children to services.
But Feigenholtz said the fact lockouts still happen shows a lack of commitment on behalf of the agencies.
“I think the question is: Shouldn’t government be stepping in and doing their job? And they’re not,” she said. “We just want them to do their job.”
B.J. Walker, head of DCFS, said the reasons lockouts happen are complex. “If law could fix problems, we’d have a different world,” she said.
Walker said many children in need of residential treatment for mental illness have such severe or unique conditions that it can be a struggle to find a facility that’s willing and able to take them.
Even for families that get state funding to pay for the care, families Side Effects Public Media spoke to said the waiting lists can run six months or longer. When parents are unable to arrange a placement, the child may enter state custody, and as ProPublica Illinois reports, they could languish for months in emergency rooms that are ill-equipped to provide long-term care. Some out-of-state facilities are not willing to accept Illinois children, citing concerns over severe delays in payments that stem from a recent two-year budget crisis in Illinois.
The program to prevent lockouts requires families take children home from the hospital after medical providers have done everything they can. But many parents say it’s not an option for them because their child remains too violent for home.
For these reasons, children continue to enter state custody as a final effort by their families to help them.
A spokesman for DCFS said in an email that, when the agency gets blamed for this problem, it’s like when a pitcher comes in at the end of a losing game to save the day and gets tagged with the loss.
What it will take to prevent lockouts
Lockouts can happen anywhere, but Heather O’Donnell, a lawyer with a Chicago-based mental health treatment provider, Thresholds, said the situation is particularly bad in Illinois.
She said a big part of the problem is that society sweeps mental health conditions under the rug until there’s a crisis.
“We don’t have a very good system in Illinois for children or adolescent or young adults with significant mental health conditions,” O’Donnell said. “What Illinois needs to put into place is a system that helps these families early on so that these kids never get hospitalized.”
That’s what the state is trying to fix now.
The consent decree issued as part of the class-action lawsuit settlement requires the state to propose a plan by October to ensure all Medicaid-eligible children in the state have access to mental health services in their communities, with changes slated to begin in 2019. Farley estimates the changes will cost the state several hundred thousand dollars, based on what it cost other states like Massachusetts to implement similar reforms.
The difference treatment and family can make
Daniel Hoy is now 23 and has been out of residential treatment — and stable — for five years. He has a 2-year-old daughter, works nights for a shipping company in Rantoul, in central Illinois, where he recently moved to be closer to his parents.
Daniel said treatment was tough, and he would not have gotten better without his parents’ love and support.
“Sometimes it’s so hard to do it for yourself,” he said. “It almost helps to know that I’m doing it for myself, but I’m also doing it for my family and for our relationship.”
Toni’s thankful that despite losing Daniel while trying to help him, they ultimately made it through intact. She’s in touch with other families that have gone through lockouts too and most, she said, are not as lucky.
That’s why Toni said she will continue to speak out about this issue. “Kids do need services,” she said. “But they also need the support of their families. And when they have both, a lot of kids can be a lot more successful.”
By brave adoptive parent and advocate Pernell Meier
Social workers have been an ever-present part of my family. Over the course of 13 years, we have parented 7 children from foster care, 5 of whom we adopted. In that time, we have had countless social workers in and out of our lives. Some have been rock-stars and stepped-up for our family and kids, advocated and pulled strings. Others have been toxic and blatantly destructive to our well-being. And the vast majority have fallen somewhere in the middle – neither appreciably helpful, nor actively working against us. Though these workers were generally decent people with their hearts in the right place, I’ve been struck by how much even caring and well-meaning social workers can be unintentionally damaging…
This amazing post goes on to provide concrete ways social workers can support adoptive families:
#1 – We desperately need your help.
Life with an emotionally disordered child, particularly one with attachment disorder, is profoundly hard…
#2 – We need to be believed.
Most of us present one way to the world and another way to those closest to us. They can turn on the charm and show their absolutely impressive best sides to you, while five minutes later becoming unimaginably cruel to us. I know that this is hard to believe…
#3 – You might be one of the only persons who we can talk to.
Most adoptive parents of high-needs kids have the same experience – friends and family fall away. The challenges are just too hard for people to process, so avoiding it is much easier. And venting to people can bring forth the inevitable, “You did this to yourself!” comments
#4 – We expect that you will be educated on these issues.
Over the years, we have found such an unimaginable lack of basic education on matters related to trauma, prenatal exposure and attachment that the process of trying to educate and explain becomes draining. We are turning to you as an expert…
#5 – When we tell the truth about our lives and our children, this does not mean that we do not love them or lack commitment.
Telling social workers about what is really going on at home backfires and gets used as ammunition against us to further cement the workers’ original views of the family. This atmosphere creates self-censorship as the adoptive parents come to view most social workers as either not helpful or detrimental.
#6 – We don’t speak social work.
You have your own specific acronyms, and ways of speaking and understanding things, just as all professions do. But when you are talking to us, please consider that we are not always going to know what you mean…
#7 – No, we are not triggering them.
Ok, let’s be real. Sometimes we do, just as any parent will occasionally handle a situation poorly. But, these children do not turn into raging, mean, or out-of-control persons because we are in general doing something to them that makes them that way…
#8 – Yes, we have skills.
We have read more than you could possibly know, called and talked with anyone we could, watched videos, taken trainings, and turned our values and our way of thinking inside out to try to make things better…
#9 – Your meetings can be painful and often feel like a waste of time.
Please know that we are likely dealing with quite a few different social workers, support persons, doctors, therapists, school officials, etc. and we have a lot of meetings that we need to attend…
#10 – You are not our child’s friend.
When you approach interactions with our children from the perspective that the most important thing is having a positive relationship between the two of you, you inadvertently damage our parental relationship because you put on those empathy blinders that do not allow you to even see, let alone confront deceit, poor behavior, manipulation and destructive dynamics…
#11 – You continually undermine us.
You set meetings with them without even bothering to tell us, thus keeping us out of the loop and making us play catch-up. You buy them things that we have said “no” to. When they have been behaving terribly and break the rules, you take them out for ice cream or fancy coffee…
#12 – You have enormous power over our lives and that is frustrating and scary.
As the gatekeeper, you are the one who gets to decide if we “need” something or we do not. When you deny us what we’re asking, please understand that this is “just business” to you and to us it feels like a hot knife slicing through us…
#13 – You get to go home.
We don’t. This is our home. This is our life. At the end of your long, stressful work days trying to make the world a better place, you get to go home to a quiet house or to your attached children, where your pets and other vulnerable children are not being abused, put your purse or wallet and car keys down without thinking to lock them away, and shrug off the day’s worries. For us, our homes often feel like prisons…
#14 – You cannot imagine our grief and our guilt.
Often co-mingled with our grief is our intense guilt. Raising a child with special needs seems to inevitably bring this on as we often second-guess and agonize over so many of the decisions related to our children’s care. Often our lives are so impossible that absolutely nothing feels like the right thing…
#15 – We need you to be honest and acknowledge your mistakes.
We need to trust you because the repercussions of you either baldly lying, withholding essential information, or manipulating us to obfuscate the truth can be devastating. In this power imbalance, you hold the cards. We have little recourse when you do things that create harm…
#16 – You hurt the kids.
Social workers will come and go, but we will always be there. You are not their parent, we are, and the best thing you can do to help them is to help us with the excruciatingly hard task of standing by them…
What’s your success been with Residential Treatment Facilities (RTF)? My son, Devon, has been in 2 group homes and 5 psychiatric residential facilities (PRTF). They feel like ‘holding tanks’ that have actually made him worse. Unfortunately, they’ve been necessary to keep Devon and my other children safe.
Here’s a great pro and con analysis from IACD. Let me know your thoughts…
Most parents who are considering residential treatment for their children with reactive attachment disorder (RAD) feel depleted. After years of therapy and countless other measures, they often feel as though their children are worse off than before. These families are close to running out of money, time, and support. The people in their lives don’t recognize what truly goes on in their homes. They just don’t get it. The parents themselves know, however, that their entire household suffers as a result. They need help.
The decision to send a child to a residential treatment center (RTC) is difficult (although sometimes that decision is made for parents which is an entirely different topic). To add to the difficulty, most parents are struggling with secondary PTSD as a result of raising children with PTSD. They are in “survival mode” themselves. If you or someone you support is in the midst of making such a decision, consider the following.
Read the Pro’s and Con’s and the complete article here.
Be sure to checkout these op-eds I’ve published on this topic:
Originally published by the Institute for Child Development.
Carol was bitter and angry—on edge. Shortly after we met through a mutual friend, she told me about her three adopted sons. She adored her youngest son. The older two were regularly suspended from elementary school, lied incessantly, and threw screaming fits daily. They teased and bullied her 10-year-old daughter.
Her husband Ted listened to us and nodded patronizingly, as if Carol was exaggerating or over-sensitive. He sighed and said that he had told her how to fix the issues but she wouldn’t listen to him. Like my son, Carol’s boys were good in front of their dad. And, like my husband, Ted just didn’t get it.
I know Carol’s desperation well because I lived it myself for years. I told Carol and Ted about adopting siblings Devon and Kayla from foster care. Devon’s behaviors had grown so extreme and dangerous he was now living in a residential treatment facility. He was ten. “I’ll do whatever it takes to keep him there,” I told them. That’s how bad life had been with Devon at home.
I confessed that, although I feel a strong sense of responsibility for Devon, I don’t love him.
Carol burst into tears. I struggled to make out her words through her gasping and sobbing. She said that she didn’t love her two boys and she’d never been able to say it out loud. It was a dark secret she kept, afraid of what others would think.
I’d kept the very same secret as Carol for years, smothered beneath a plastered smile. Love came surely and steadily with Kayla. But it never did with Devon. I was sure something was wrong with me and was driven nearly mad in my quest to love him. I struggled to bond with this little boy who spit in my face, kicked and hit me, threw objects at me, destroyed my home, dismantled my marriage, and tormented my other children.
People understand why a woman wouldn’t love an abusive husband or partner. But this is a child.
We don’t like to admit that even a young child can perpetrate domestic violence. In fact, well-meaning family, friends, and professionals insist that all these children need is love from a “forever family.” With these platitudes condemning us, adoptive mothers struggle to find help.
Carol and I kept what was happening in our homes a secret. Here’s why—
We didn’t realize we were being abused. We refused to believe it’s happening because child on parent violence is taboo in our society.
We felt responsible. We believed our children would behave differently if only we could be better mothers.
We believed things can change. We kept trying to fix it, holding onto hope that we can keep our adoption dreams alive.
We feared how others would react. We worried about letting down family and friends who have supported our foster care or international orphan adoptions.
It took years to get help for myself and Devon. Eventually, I learned he had gone through early childhood trauma and he was diagnosed with reactive attachment disorder (RAD). While not all children with RAD are violent, some can be.
I came to understand that my emotions of anger, frustration, exhaustion, and bitterness were normal. My therapist helped me see that feeling love for a person abusing me–even a child–was not natural, normal, or healthy. It’s unfair to expect adoptive mothers to love children with these extreme behaviors and issues. Faking-it-until-you-make it in front of friends, family, and professionals is not the answer. “It’s unreasonable to force a parent to bond with a child whose behaviors have led to his or her PTSD,” said Institute for Attachment and Child Development Executive Director Forrest Lien. “The whole family needs healing in order to foster parent-child attachments.” These mothers need compassion, understanding, and support rather than shame and guilt.
For the sake of Carol, and countless other moms who have been shamed into the shadows, I choose to be a silence breaker. I’m not proud that I don’t love my son in that emotional way, but I’m no longer ashamed.
Published by Institute for Attachment & Child Development
A sweet little kindergartener, with a Blues Clues backpack and big brown eyes, Devon went to school every morning with a hungry belly. At least that’s what he told the bus driver, his teacher, and the cafeteria ladies. When I got the call from his school, I was positively indignant. Not only did Devon eat breakfast every day, but he usually had seconds.
Within a few years, Devon’s lies had become dangerously calculated deceptions. “I’m gonna hurt myself and tell them you did it. They’ll arrest you,” he’d say cooly, before punching himself in the jaw. Other times he’d twist the tee-shirt he was wearing round-and-round, cinching it against his neck until it left a puffy, red ligature mark. He’d accuse me of strangling him.
Unfortunately, many children with reactive attachment disorder are capable of false allegations. “Due to early trauma, children with reactive attachment disorder feel safe when they can control their environments and push away people who try to get close to them,” said Institute for Attachment and Child Development Executive Director Forrest Lien. “False allegations are one way for them to achieve both.”
Even if we understand the diagnoses and social histories that prompt our children’s false allegations, however, being lied about can be infuriating and hurtful.
A child’s allegations, however outrageous or unlikely, will be investigated. This unwarranted disruption and family upheaval is collateral damage, necessary to make sure children who really are abused get the justice and safety they deserve. “By law, police officers or child protective service workers investigate all allegations of child abuse, as they should. Child abuse allegations need to be taken seriously,” says Institute for Attachment and Child Development Executive Director Forrest Lien. “On the other hand, it’s also harmful for children to falsely accuse adults of abuse charges.” The consequences of false allegations can be devastating if our children, master manipulators, manage to convince a guidance counselor, therapist, or police officer they’re telling the truth. Parents can unjustly face jail time and lose their children without reason.
Here are 6 steps you can take to protect yourself and your family if your child makes false allegations against you:
1. Keep a daily log. I use small notebooks that fit easily in my purse and document conversations with social workers and teachers, write notes after therapy appointments, and record details of any behavioral incidents. I also write down what my son eats for breakfast, what activities we do, and what time he goes to bed. The key is to be consistent and document even the mundane. Your log will be much less credible if you only log when an incident occurs.
2. Gather documentation. To establish a pattern of behavior, keep school disciplinary records, ask people to follow up on calls with an email, and, if your child is admitted to a treatment program, request their records when they are discharged. These documents may have mistakes or minimize your child’s behaviors so comb through them and request any corrections. Discuss false allegations with your child’s therapist. Your child may admit the truth to them and this can be documented.
3. Don’t lose your cool, or your credibility. When a therapist, teacher, or others bring an allegation to your attention, listen. Breathe. Keep the frustrated tone out of your voice, don’t jump to defend yourself and never exaggerate. Sometimes you’re going to find yourself in a she said–he said and your credibility will be everything. A non-defensive response might sound like: “Gosh, I fed Devon eggs and toast this morning, but thanks for letting me know that he told you he hadn’t eaten. If he ever does miss breakfast, I’ll be sure to email you so we’ll be on the same page.”
4. Use video/audio recordings (sparingly). This is a tricky one that can backfire. First, remember that your words and actions on any recording will be judged, probably more harshly than your child’s. Second, you may be accused of provoking your child by recording them, especially if they scream at you to stop. In a few instances, I’ve been successful flipping my cell phone recorder on without my son seeing it. Give that a try.
5. Don’t go it alone. If things are spinning out of control, call a family member or friend to come over to act as a witness. Sometimes you may have to resort to desperate measures. For example, my son currently lives in a group home and I’ve refused to have visitations with him unless we are in a room with cameras and a staff member. We’ve had to cancel and reschedule visits because of this, but I cannot risk being alone with him.
6. Have a backup plan. Have a contingency plan so your other children do not end up in foster care if social workers remove them during an investigation of a false allegation. My sister and her husband have agreed to take my children if this should ever happen to me. It’s a worse case scenario, but you need to be prepared with a plan.
Though my son has hurled devastating false allegations against me, I’ve been able to avoid the worst potential outcomes by being proactive and meticulous about documentation. It’s extremely sad that I’ve had to do so. Yet, it’s a devastating reality that many parents of children with reactive attachment disorder must face to save their families.
How did resilience become a standard? How did we come to view children almost as nuisances who just need minimal support? How did children’s needs become dismissable?
