Pop Quiz # 3 A Mother's Choice

[PorcupineWhisperer]

In the past I posted a couple of 'Pop Quizzes' or dilemmas that I have run across in the therapy world. Sometimes, there are no right answers. Here is the latest....

By most definitions, at age 13 'Junior' could be described as a 'pre-sociopath'. He has killed and tortured animals, has threatened to kill both his mother and sister in the past, he describes himself as a pyromaniac and states that he finds fire 'pretty'. He has been hospitalized multiple times and is on his 3rd Residential Treatment Center (RTC) placement.

The mother, after exhausting all treatment options signed custody over to the state in an effort to get him the long term help he needed. After almost a year in his current placement, Junior has started to make progress - he is less violent, he is able to go on outings with mother and sister and not be threatening, he is able to address his past behaviors in therapy.

Mom was becoming hopeful....

In the state of Texas there is an agency that evaluates all the kids in state care to determine if they are in the least restrictive placement possible. This agency has reviewed Juniors records and determined that despite Juniors - ongoing aggression (peers and adults), being intentionally cruel to younger peers, stealing, lying, history of sexual acting out, suicidal statements as recent as last month and tantrums that can last for an hour or more - this agency feels that he is ready for a foster home. Despite multiple appeals, a recent psychiatric evaluation that recommends continued placement in a locked environment and describes him as violent with a lack of regard for others - he has to be moved.

What's a mom to do?

A. Allow him to be placed in a foster home - his last foster placement lasted about two months and ended with him being hospitalized and accused of some type of sexual activity with one of the younger children in the home. Although he does not know that he is leaving, he has been adamant that he does not want to go to another foster home and is likely to be disruptive just because he does not want to be there.

B. Allow him to come home - he wants to go home and may be willing to work harder to maintain at home then in a foster home - but then there's the whole past homicidal threat thing. He was very violent when he was at home - but it's been almost four years since he's lived there. Mom is a single parent who does not have a lot of family support.

C. Allow the state place him in another Residential Treatment Center (RTC). There are none in the area and Texas is a big state. He could easily be placed in an area where mom could not visit him regularly. Despite past problems, he and his mother are very attached.

Good Luck!

 

[Hound dog]

Am I supposed to be the "Mom" in this situation?

If I'm the Mom, then I opt for C, letting the state place him in another Residential Treatment Center (RTC). Although I might be very attached to my child, the last thing I'd want is for him to have the opportunity to hurt someone. With his past behavior and ongoing problems, I'd say Junior is nowhere near ready for foster care or to be sent home. It would most likely be a very painful decision. But it's the one I'd make.

 

[flutterbee]

Answer: C.

 

[timer lady]

Hey PW - checking in on us? Making sure we're making the right decisions? Hmmmm?

Given the state of TX & it's lack of resources & such; it's inability to "bend" the rules even though it may be the best case scenario & the fact that mom has little to no support in the home environment I'd opt for C.

Would it be my best option? No - I'd want to be closer. However, difficult child has yet to prove himself in the community; he's not shown the ability to learn boundaries. The hints that he is beginning to show how his actions have impacted others & himself are a start. I'd still have to go with C. And my heart would be broken.

 

[Hopeless]

I would also opt for "C"

 

[JJJ]

"C" also. But if the State has determined that he doesn't need to be in an Residential Treatment Center (RTC), is it even an option??

 

[meowbunny]

I'm with JJJ. How can Residential Treatment Center (RTC) be an option if the state has said no to keeping him in an Residential Treatment Center (RTC)? First choice would be C if it's available. Otherwise, it would be A and I'd do my best that he not be in a foster home with younger children.

 

[tiredmommy]

What MB said.

 

[daralex]

What a horrible situation! Not leaving much of a choice. I would also have to say C as being the lesser of evils but it ***** no matter what!

 

[slsh]

My first thought also was that if Mom has given custody to the state, she would have no say.

Assuming there's no choice D (none of the above), C has to be it.

I don't think it's possible to ignore the level of behaviors that you describe and trust that Junior will be able to maintain safely at home now in spite of the passage of time and recent progress. been there done that. I could be completely wrong (and am, according to thank you) but I think before a return home there has to be a consistent demonstration of appropriate behaviors in lesser restrictive placements. Junior's stated refusal to cooperate in foster care doesn't bode well, in my humble opinion.

Just my 2 cents.

 

[DammitJanet]

I have to agree with the others. As a parent of a grown kid with sociopathic issues (though not the violence) I cannot see where bringing him home at this point can even be an option. The violence would scare me to send him into the foster care system. His threats show that he would sabotage any efforts there. The only semi-safe choice is C.

 

[Marcie Mac]

Its really a no win situation isn't it - A would perhaps mean undoing all of the progress that has been done, C would perhaps mean undoing all of the progress that has been done, and now he probably won't even have the connection of mom

I will be the odd duck once again. Personally, I would go with B IF supports were in place, and my attorney made it clear to the State of Texas that if anything would go amiss, they are going to be held accountable since they have made the bonehead choice of taking a child who is making progress out of a current placement despite information that it would be detrimental.

Marcie

 

[PorcupineWhisperer]

Ahh, Perhaps I should clarify the Residential Treatment Center (RTC) issue. Texas has a four tiered Level of Care system to determine a child's placement. They range in severity : Intensive, Specialized, Moderate, Basic -with Intensive being the most severe. Junior's current LOC is Specialized but he is about to fall to Moderate as of February 1st. His current placement is only licensed for Intensive and Specialized and therefore he must be moved by January 31st.

There are residential placements that take Moderate kids, but they tend to be places like boy's ranches and group homes that don't provide the supervision or the therapeutic skill that a kid like this is going to need.

At present, Mom is torn between wanting here son home, being able to provide a safe environment for all involved and not wanting him to get lost in the system.

Mom, has to decide soon. I'll keep you posted. For the record, I would go with B. I think if a local foster home could be found this would allow him continued contact and visitation with his family as well as well as continuing to work with his current therapist (me ) and slowly integrate back into the home over time. And if he fails (which he is likely to do in any new environment), at least he won't do damage to his family relationships that could have a permanent impact.

 

[timer lady]

PW,

As the therapist it's "easy" to opt for B. However, finding a foster home (preferably a MITH level therapeutic foster home) these days is iffy at best.

husband & I are lucky in the home we found for wm; the closeness. However, we have a team of 12 people working for this young man, not including husband & myself. You add in husband & myself you have the equivalent of 20 or more people.

Keep us posted. I have a wonderful group of MITH type homes here in our area - not even close to TX though.

 

[mstang67chic]

Mom, has to decide soon. I'll keep you posted. For the record, I would go with B. I think if a local foster home could be found this would allow him continued contact and visitation with his family as well as well as continuing to work with his current therapist (me ) and slowly integrate back into the home over time. And if he fails (which he is likely to do in any new environment), at least he won't do damage to his family relationships that could have a permanent impact.

My initial thought was to go with C also. After reading your comments though, I can see the positives in situation B. However, my concern would be that he might still harm someone in the foster home, at school or even in the neighborhood. He would have to be placed with very skilled foster parents who were well informed ahead of time. I say that because when we got difficult child as a foster, we were told basically squat. We knew that there were issues but no one told us how involved those issues really were.

Either way Mom goes, it's tough and my heart goes out to her.

 

[susiestar]

This is a very difficult decision.

A recent psychiatric evaluation said he is dangerous and needs a locked environment. This does not sound like he is ready to be moved down a level.

Mom signed custody over, does she really HAVE a say? I know in OK if you sign over rights then you sign over your decision making ability completely (We looked at this a couple of years ago).

He has a sister. If she is still at home the young man ABSOLUTELY CANNOT be sent to the same home. Finding foster care that can handle a child with the level of violence and care will be a huge challenge.

If that home can be found near mom, then it might be worth trying, but the home should not have other children.

They should be ready to send him to Residential Treatment Center (RTC) at the first sign of violence, if they go the foster home route.

I do think choice C in a locked facility, will give him the structure he needs and the therapy he requires to someday be a productive member of society.

Susie

 

[timer lady]

PW,

Just out of curiosity, what method would be used to determine if either of these options is a success? How much input would difficult child have on the determination of yea or nay?

What time frame would difficult child have to transition to a foster home or to home? As difficult child has been out of the home for 4 years I would assume a drop down to foster care to "prove" himself in the community & then another drop down to home. difficult child would certainly have to "show the money", if you will, if he really wanted to move onto home.

Would mum have in home services on board? I'd be leery of an adolscent difficult child moving back home after 4 years with-o daily check in's by some big burly male making sure difficult child is on track. How long would it take for crisis team to show up to help mom out or does she dial 911 & ask for help with a mentally ill child? This is a serious question.

What self calming skills is difficult child working on; does he have a reminder phrase that he will respond to from an adult? kt's phrase is "excuse me" or "stop & think". That's all we say - generally she takes a hint from that, other times it escalates to crisis team &/or 911.

Is difficult child "using" his illness to scare & intimidate others & the family? Again a big concern.

Personally, while I have a family of different addresses (& I hate it), I have a safe family of different addresses. These are the same concerns & questions I would have before I would even consider bringing wm back under our roof.

I signed over physical custody of wm to the state. I'm am still his legal guardian & as such, am responsible for my son. I make all the treatment decisions, still sign all the HIPPAs & attend the IEP mtgs & such. I'm not sure the situation of your patient in TX.

 

[PorcupineWhisperer]

TL: I think the easiest method to determine success would be his being able to mange in any of the environments that he might be placed in. To me this means not having to be placed in another locked facility (or hospital) due to excessive aggression, self harm or sexual acting out.

As far as a time frame for transition to a foster home, if 'lucky' he would go right from the Residential Treatment Center (RTC) to his foster placement. If not (ie no foster home can be found that would take him), he would likely go to an emergency shelter until something could be located.

In regard to services, short answer not alot. Mom wasn't even sure if she could get respite care. This is important because mom is trying to finish school so that she will have a career to support her family. She has already had to quit once due to her son's high level needs.

In regard to coping skills he has some and has been using them more lately. But since he has not used them consistently in the Residential Treatment Center (RTC), I wonder about how effective they would be during a conflict in the lunchroom or while unsupervised with peers at the local rec center. I did ask his psychiatrist to prescribe a PRN (Risperdal) as an aid in helping him calm down if things get rough.

He would be going to public school and let's just say that last time around, this was not a good experience for anyone involved.

As far as a 'crisis team', there isn't one.

The state does have custody of Junior, but mom still has rights and the judge stipulated that she could have him back when he was ready to return to her home.

I think the difference in Wms'. case and Junior's is that Wm. was lucky enough to have the option of a local specialized foster placement. In Texas I have yet to see a FH with one or two high need kids. You either have homes that have 5-6 kids of mild to moderate behaviors (like the one he was placed in before) or homes that might have 1-2 kids that have no behavior issues or might have significant medical issues. Truthfully, I think finding any kind of foster placement is going to really be hard - let alone a really good one.

I don't think he is using his illnes to try to scare the family, but he is a scary kid and he knows it. I think he wants his life to be different and has really worked hard to make the progress that he has.

Someone asked what choice he has in the matter (I apologize that I forgot who). Becasue his impending discharge hit everyone involved as such a surprise, we don't really know what the options are fully. For example, the state hasn't said that they fully suport him going immediately back to mom but then they also acknowledge that finding a foster placement would be hard.

The one thing that is for sure (short of some last minute miracle or appeal), he has to be out of his curent placement by Thursday (being a locked facilty, they are not licensed for his lowered level of care).

 

[timer lady]

Sorry, PW, this situation terrifies me for your patient & his family. If there is no qualified therapeutic foster home for difficult child to step down to to prove himself in the community.....

Another phrase you brought up is "while unsupervised" - PW, we've had intense one on one services for tweedle dee & tweedle dum for going on 7 years now; neither are left unsupervised for any period of time (10 minutes max I believe it is for wm before he MUST check in).

I have to tell you, my good man, none of this looks good from a parents point of view. I'm sitting here shaking my head.

I'm not saying it can't be done at home with mom - but the supports aren't there. Even with the best of supports/services you get burnt out.

AND I know there are few options going on...I'll keep this family in my thoughts & prayers.

 

[Star*]

Well tell this poor Mom 1st she needs to come here for support. Is she getting any at all?

I am going through the exact same thing currently with my 17 year old son- although no threats to kill or set fire - he's a very unstable person at times.

Sending him out of state - ISN'T this care all about reunification with family?

Sending him home - Didn't he threaten to kill his family and set fire? DIdn't the mom sign him over so her family could be safe?

Sending him to a new Residential Treatment Center (RTC) - WHY OH WHY OH WHY does this happen everywhere. I'm getting ready to attend a conference next month to discuss how to improve the system and the VERY FIRST NUMBER ONE THING ON MY LIST - LEAVE THE KIDS WHERE THEY ARE, stop freaking moving them around and around - it's not a good thing - my son is living proof. 18 months isn't long enough to help you do more than get over acne. And I don't have a masters in child psychology - HUGE INFLATED GINORMOUS DUH.....

So none of the above are options. Telling the state team that evaluated him what could potentially happen if he's moved to A, B or option C may go a long way to keeping him where he is.

Simplified mathematics: ask them =

Do you want him to continue making progress? Yes - keep him where he is at.

OR

Do you want him to murder a foster family in their sleep and burn down a house? NO? Okay foster care is out. Oh that doesn't bother you? Ask the foster family he's going to live with first if that would bother them? Maybe it will end that venture.

DO you want him to murder his own family in their sleep and burn down their house? No? Okay - moving back home is out. This you should know as the criteria for a mother to sign her son over to the state shouldn't allow that child to come home until full rehabilitation for YEAR is done. If they don't think that's a bad idea - then THEY need therapy. HOLY MOSES IN A REED BASKET. Id' tell the state the first sibling to hit the ground dead and in flames - wins????? HONEST TO PETE ARE THEY FOR REAL?????

Do you want him to START ALL OVER AGAIN at some new Residential Treatment Center (RTC) where he can't and won't build bonds of trust with a therapist or psychiatrist for at least 18 months and then move him again - mean while he has NO FREAKING support of his family - OH sure - that sounds best to you - well NOT TO ME.

This system is just stupid - no one wants to make a commitment with kids like mine because - because mostly because while we say My son is capable and has done x,y,z - professional people look at the parent like "Well he does x,y,z, because you have done a,g,1,and maybe. f. Then they get the kid into the system, start talking to him, learning about him and figure out that THEY THEMSELVES GODS OF THE CHILDRENS PSYCHE graduating to save the bleeping world - can't do a damn thing with these kids either - there is no science, so they lump him into psychotic with the future of a career criminal and just try to PUSH HIM THROUGH THE SYSTEM so they can "get ahold" of the next child who (as I've been told a dozen times) REALLY WANTS THEIR HELP.

In other words PW - they are looking for the EASY way out ,and need a child that they can cure and feel like they have a success story with - to feel better about themselves because college couldn't have cost this much for this long - and not yielded any results with children. AS IF ANY OF THEM HAD A STINKING CLUE -

BECAUSE if they HAD A CLUE - they wouldn't move that child from where he is starting to see success from in the first place.

AND that my brother is the truth!

LIVED IT, STILL LIVING THE DREAM and didn't even get a lousy Tshirt.

So tell your friend - she's not alone - and that there are no good answers or options because the option that makes sense isn't on the table and they won't put it there - so tell her to LET THEM CHOOSE. And when people are dead or in flames - she looses a son and they just go "Gosh we were wrong about that one, live and learn."

Done preaching - the choir may be excused to go to bible class.

Star