A difficult parent: when parent-child attachment is fragile.

Mrs. Forrest brought Jackie, her 11-year-old adopted daughter, to her pediatrician with a range of concerns, including problems with attention, school performance, anxiety, and frequent oppositional behaviors. Jackie was removed from school because of her mother's concern that the "school was not doing enough" to help Jackie. School reports were not available at this visit. Her mother reported going to great lengths to seek help for Jackie, including individual and family therapy, a psychological evaluation, academic tutoring, and a variety of home-school curricula. She planned to enroll Jackie in a residential treatment program. Little is known about Jackie's early childhood experience. She may have been exposed to alcohol and drugs during the pregnancy. Jackie lived with her biological mother until age 3 years, at which time she was placed in foster care because of allegations of abuse and neglect. She was in multiple foster homes until she was adopted by Mr. and Mrs. Forrest at 6 years of age. Mrs. Forrest's description of Jackie's oppositional behaviors was vague, and when asked to cite specific examples of these behaviors, Mrs. Forrest replied, "Unless you live with her you will have no idea how she really is." With Jackie present in the room, Mrs. Forrest stated that Jackie "is wrecking our family," and that she and Jackie "have never been attached to each another."When interviewed alone, Jackie was noticeably upset by what her mother had said; she displayed a sad affect. She expressed remorse for "being bad" and a desire "to get along with my family" and "to go back to school." She drew a picture of herself and her adoptive mother smiling and eating ice cream together.Over the next several months, Jackie's mother insisted that the pediatrician prescribe medication to manage Jackie's behaviors; she became upset when he expressed reluctance. She was resistant to a recommendation for family therapy, although she did place Jackie in individual therapy. At this point, Jackie's pediatrician became aware of his feelings of anger and resentment directed toward Mrs. Forrest.