ETHICAL CHALLENGES IN FAMILY WORK

Because of its complexity, work with families places extra demands on practitioners, who must strive to be fair, objective, and self-aware even during very intense emotional interactions. The goal of maintaining professional neutrality may be especially difficult when the lives of young children are at stake and the impulse to “rescue” them is ignited in the worker. Often individuals enter the helping professions because of their sincere, altruistic motivation to help people, such as children, who for various reasons cannot help themselves. What is the danger, then, in wanting to “rescue” children? From whom or what are they being rescued? And what will become of them after the rescue? There is a significant difference between helping and rescuing, because the implication in “rescue” is that the individual is being removed from a dangerous situation. In my opinion, a child-rescuing mentality serves to establish a barrier, rather than a bond, between a practitioner and a parent. When the worker becomes judgmental toward the parent, his or her ability to work effectively with the parent is greatly reduced, and ultimately the child suffers. Work with children requires the ability to relate to their parents. This relationship, however, inevitably stimulates memories and overtones from a practitioner’s own family of origin. In supervising child therapists, and in my own work, I have often traced a lack of empathy or other therapeutic impasses to experiences in the practitioner’s own family of origin or present family (Webb, 1989). “Countertransference can be triggered by identification with one of the clients, the family, the style of communication, and similar events in the therapist’s life” (Miller, 1994, p. 16). Therefore, it is incumbent on practitioners working with families to be self-aware and to receive regular supervision or consultation to help them recognize areas of possible identification with the families with whom they are working. Efforts to help children without attention to helping their families are shortsighted and will have limited impact. Admittedly, trying to empower a family to help itself may seem more formidable than spending time individually with a child. However, more attention must be focused on this essential larger task if we are truly to integrate child and family helping. Confidentiality is another thorny issue that frequently comes up in the context of family work. I have noted in Chapter 2 that children really do not have the legal right to confidentiality with respect to their parents, whose status affords them power to demand that a child reveal certain matters or who may require that a child’s medical (counseling) records be revealed to them. When these matters come under dispute, the court may appoint a guardian ad litem to represent the child’s best interests, but even then the child’s position may be ambiguous and conflicted if he or she is caught between the demands of two hostile parents in a divorce proceeding. This situation is discussed more fully in Chapter 11. Consistently in this book, I present the position that confidentiality between parent and child is neither feasible nor in the child’s best interests. I argue for open communication between parent and child to increase their understanding of each other’s needs and feelings. When the child and parent treat each other with respect, confidentiality will not be a concern. Practitioners must consistently help families work toward this goal. INTEGRATING CHILD AND FAMILY THERAPY IN WORK WITH (OR DEALING WITH) ATTENTION DEFICIT/HYPERACTIVITY DISORDER AND CHILDHOOD GENDER IDENTITY ISSUES The remainder of the chapter focuses on helping children and their families deal with two different problem situations in which involvement of both the child and the family is critical to bring about some improvement. The two conditions are attention-deficit/hyperactivity disorder (ADHD) and gender identity issues. Although the child is designated as the “identified patient” in both circumstances, involvement of the family is essential to help motivate and encourage the child to persevere with the short- and long-term treatment goals and to achieve a positive sense of identity. Both childhood conditions are considered serious, requiring lifelong attention and commitment for successful outcome. Attention-Deficit/Hyperactivity Disorder A diagnosis of ADHD usually follows some years of the parents’ increasing awareness and growing concern about their child’s difficulties in following instructions, very high energy level, and constant distractibility. This disorder is more common in boys than in girls and is found in approximately 6.8% of children (Nigg & Nikolas, 2008). The onset of the hyperactive behaviors usually occurs before the age of 3, but many children do not come to professional attention until around age 7, when they cannot meet the additional demands placed on them in school. ADHD is a biologically or constitutionally based disability of unclear etiology. According to DSM-5 (American Psychiatric Association, 2013), the characteristics of children with ADHD include two different groups of behavior: (1) symptoms of inattention and disorganization (e.g., easy distractibility, forgetfulness, lack of follow-through, difficulty organizing tasks and activities, and careless mistakes) and/or (2) symptoms of hyperactivity–impulsivity (e.g., fidgeting, excessive talking, seemingly “motor-driven” activity, interrupting others, blurting out answers, and difficulty taking turns). A formal diagnosis of ADHD requires at least 6 out of 9 possible behavioral characteristics in one of these two subgroups (or 12 out of the total of 18 in both) “that have persisted for at least 6 months to a degree that is inconsistent with developmental level and negatively impacts directly on social and academic/occupational activities” (American Psychiatric Association, 2013, p. 59). Social workers who want to recommend a reference to help parents understand this condition can suggest Russell Barkley’s numerous books on the topic (2006, 2013, 2014). Barkley’s books on this topic would also be helpful for practitioners who want to learn more about this condition (Barkley, 2006; Barkley, Robin, & Benton, 2014). Other useful references are Pelham and Fabiano (2008) and Pelham, Guaggy, Greiner, Fabiano, and Waschbusch (2017). Palombo (2002, p. 144) describes the situation as follows: The profile of an individual child’s neuropsychological strengths and weaknesses is analogous to the topography of a landscape. For some, the terrain is fairly flat; that is, their competencies are evenly distributed. Other children’s profiles look like a terrain filled with prominent peaks. These children are gifted in multiple areas. Yet the valleys between the ridges indicate that their gifts are rarely uniformly distributed across the entire terrain. Gifted children may also have learning disorders (Vail, 1989). For children with learning disorders the terrain is highly variable. There are peaks and valleys that are notable for the contrast they present. The valleys Obviously, these differences create great uncertainty for parents and for teachers who find it difficult to understand and accept how a child’s behavior can vary so greatly. See Dane (1990) for more discussion on this topic. Dif erent Helping Approaches A multimodal approach is most effective in helping children with ADHD and their families. Specific interventions include psychostimulant medication, usually methylphenidate (Ritalin); behavior management skills training for the children’s parents and teachers; cognitive, supportive, and play therapy to enable the children to develop self-esteem; and supportive counseling for parents. Several of these methods were employed in the case of Tim (see the next section). Mash and Terdal (1997, p. 111) state that there is overwhelming evidence for the efficacy of stimulant drugs in conjunction with behavioral interventions in the treatment of children with ADHD. Both procedures require family support, as demonstrated in Tim’s case. Family Considerations The impact of living with a “hyped-up” child with many distractible and agitated behaviors cannot be minimized. Children with ADHD do not slow down, and even when watching television they may bounce on the couch, poke or tickle a sibling, and/or laugh raucously and fall on the floor. Bernier and Siegel (1994, p. 146) state that “the child’s noncompliant, disruptive behavior contributes to chronic stress in parents, which in turn produces unproductive parenting behaviors that exacerbate the ADHD symptoms.” The cycle of negative parent–child interactions that often characterizes a family with a child who has ADHD results in fewer gratifications in the parental role and reduced parental self-esteem. These factors in turn sometimes precipitate or aggravate parental problems, such as depression (Bernier & Siegel, 1994). A focus on the parents and the family system, therefore, is essential when working with a child with ADHD. If the practitioner can effectively support the parents, this may help to prevent a negative cycle of behaviors that could become worse as the child gets older (Hallowell & Ratey, 1994). The case discussion that follows illustrates some cognitive-behavioral approaches in work with a 7-year-old boy with ADHD and his family.