Treating the Whole Child, Not Just Symptoms

By Dave Ziegler, Ph.D.

In a recent conversation with a fellow psychologist, it occurred to me that our treatment systems seldom consider all aspects of the child when treatment/service plans are developed.  An analogy with fixing a car came up.  After a serious accident with a vehicle (analogous to the wrecked lives of many clients) we receive an estimate on fixing the entire car – the engine, the frame, the windows, the exterior paint and any interior damage.  If we received the car back from the shop with some but not all of the necessary repairs the job would only be partially complete.  But consider how many children are referred to treatment to help them stop specific problem behaviors.

Treating an individual requires consideration of the whole person including any and all aspects that need healing and special attention. There are multiple advantages to taking a comprehensive orientation to treatment.  Problem behaviors are generally more complicated than they appear.  A limited intervention might produce a temporary change but may not address the causes of the problem.  People are complex and the human brain is the most complex organic structure in the universe.  All successful interventions must impact the brain.  The most lasting treatment will produce positive brain change or changing the individual from the inside out.  The more comprehensive the approach, the more impactful it is likely to have.  The interventions that are the most efficacious and cost-effective in the long run are integrated treatments.

So what does integrated treatment look like?  To start with it is treatment that acknowledges that a problem in one area, or a strength in one area, will impact other areas as well.  The whole person could be considered a combination of mind/body/spirit or 1. Mental/Neurological, 2. Physical, and 3. Spiritual/Attitudinal.  Each of these three overarching areas can be broken into any number of additional areas, but for the purposes at present I will mention ten areas under each.  As you read these areas, ask yourself how each could be addressed in a service plan for a child you are working with:

Physical

  1. Personal self-care
  2. Nutritional intake
  3. Engagement in life skills of daily living
  4. Attachment/social skills
  5. Optimal sleep
  6. Activity and exercise
  7. Communication skills
  8. Pleasure and pleasurable pursuits
  9. Relaxation/allostasis
  10. Play and playfulness

Mental/Neurological

  1. Functional internal working model
  2. Growing access to higher reasoning brain involvement
  3. Challenging mental activity/academic growth
  4. Active imagination
  5. Focused attention/meditation
  6. Coping/resiliency
  7. Perceptual clarity
  8. Developing intuition
  9. Healthy emotions
  10. Balance of past/being in the moment/future orientation

Spiritual/Attitudinal

  1. Sense of connection to something greater than self
  2. Optimism
  3. Self-reflection/contemplation/prayer
  4. Joy/personal contentment
  5. Gratitude
  6. Altruism/kindness
  7. Social connectedness
  8. Ability to forgive
  9. Respectful disposition
  10. Positive orientation

The above list at first glance may appear daunting, but effectively treating the whole child is among the most complex tasks there is.  The good news is that the thirty discrete areas are artificially separated and overlap considerably.  For example, developing a positive orientation promotes optimism, emotional health, clarity of perceptions and engaging higher reasoning centers of the brain.  There are differences with each area.  Initially, attachment and social connectedness may sound the same but there are differences in the way both can be represented.  For example, some children superficially connect or have the skills to do so, but lack the interest.

While overlapping, the above list is separated into areas as a reminder of the importance of each to overall health of mind, body and spirit.  Routine outpatient mental health treatment may involve only five to eight out of thirty areas unless other issues are brought up as problems.  Standard residential treatment may expand this to twelve to fourteen, but this is less than half of the full list.  Addressing this list of thirty areas is not to say that each area needs extensive attention or equal time.  Considering the full list can remind both the therapist and the other adults in the child’s life of the importance of some of the areas that routinely get little or no attention.  Ignoring any of the items is to diminish the chances of overall health.

Before going into an explanation of the thirty areas on the list, it may be helpful to see how the areas overlap.  Looking at a child’s overall health can help identify potential problem areas because of the substantial overlap.  If a child is obese the chances are good that a number of physical areas are deficient (self-care, nutrition, sleep, activity and play).  But this would likely not be the full picture because deficiencies in any or all of these areas may produce poor internal perceptions, a negative internal working model of self, emotional problems, lack of optimism and a barrier to connecting to others.

One way to view how the areas overlap is to consider a graphic representation of the whole child.  Some areas are somewhat distinct to one or two areas and others overlap in all three main divisions of mind, body and spirit.

 

Treating the Whole Child: Mind, Body & Spirit

 

To say that this is all too complicated and we need to simply focus on a few externalized presenting symptoms, is like getting your car back from the shop with half of the problems addressed following an accident.  If this is unacceptable with repairing a car, why should our standard be lower with a child? Treatment occurs not only in the therapist’s office but also at home and in the classroom, so some of the interventions mentioned take place in all aspects of the child’s world—thus integrated treatment.

Some descriptions and interventions can be helpful.

Physical

  1. Personal self-care – the skill and interest to take good care of oneself is critical to overall health.  Characteristics such as being selfish, egocentric or self-interested are not the same as self-love or self-care.  Excessive focus on self may indicate a negative sense of self.  Building upon self-care is fundamental to promoting health and can be accomplished with setting external standards and teaching self-care behaviors at all ages.  When adults encourage self-care it can provide dividends in self-image.
  2. Nutritional intake – the statement that we are what we eat is especially true for children who are in the system of care.  Poor early eating habits are common and they will not change without intervention from the outside.  While there are a variety of opinions as to the best healthy diet, there is general agreement about what constitutes an unhealthy diet (processed, artificial ingredients, high fructose corn syrup, and excessive calories).  Learning to cook, growing a garden, and shopping at the farmers market are all fun and learning opportunities to involve children in developing healthy nutritional habits.
  3. Engagement in life skills of daily living – engagement is a building block of happiness.  To get more out of anything one must invest more into it.  Daily living skills are important to making life more manageable and less stressful.  Competent living skills are a part of a successful life.  All children need chores to help with the household, but give them meaningful and varied chores so they learn skills and enjoy helping at the same time.
  4. Attachment/social skills – the ability to attach and bond is one of the foundations of a happy and healthy life.  Humans need others to survive and thrive.  Few children develop ideal attachment skills growing up and must work on trust, vulnerability and loss throughout life.  Social skills are a means to connection with others and are some of the most complex abilities to understand and demonstrate.  Find fun activities to do with the child to enhance attachment.
  5. Optimal sleep – from brain research we know that sleep is not for the lazy, it is for the smart.  The role that sleep plays in a healthy lifestyle is only recently becoming clear.  Deep sleep (REM) repairs the brain, consolidates memories, and recharges alertness and attention.  Short periods of sleep during the day have been shown to have multiple advantages to energy level, stress reduction, better mood and attention span.  The optimal amount of sleep varies by individual, but at least 8 hours for adults and 10-12 for children are recommended.  Have an evening ritual before bed, for example, lower the lights, reduce stimulation (turn off the TV), have some quiet time reading in bed then lights off.
  6. Activity and exercise – this is one of the least acknowledged paths to health and one of the most accessible.  Physical activity is not only good for everyone, it is fun and has many advantages including weight control, coordination, developing motor skills and many more.  Aerobic exercise could be considered the “fountain of youth” at any age because of the many health effects such as heart health, respiratory capacity, bone and joint repair and has been found to be the single most important path to brain health.  Pick a physical activity a child might enjoy and then do it together, such as a family walk/jog, hike or bike ride.
  7. Communication Skills – the ability to communicate with others through language, signs, and written forms set humans apart from all other living creatures.  To be fully healthy requires social participation and communication is the primary vehicle.  Human communication is extremely complex and we must grow throughout our lives in our understanding of all the ways communication can be effectively utilized.  Teach communication skills, have family discussions on topics and have a weekly family meeting where everyone interacts and can give opinions.
  8. Pleasure and pleasurable pursuits – somehow pleasure has received a negative reputation, perhaps because moderation is difficult when something provides pleasure.  Pleasure is one of the primary ingredients of happiness and improves motivation, laughter (very healthy in its own right) and stress release.  It is a principle of health that the brain pursues pleasure and avoids pain.  Find something fun to do with your child such as rent a movie everyone can enjoy and make some snacks to make it special.
  9. Relaxation/allostasis – managing stress through relaxation has long been recognized as a key to emotional and physical health.  The ability of the body to have a broad range of physical and emotional activation as well as deactivation (allostasis) is a key aspect of self-regulation and emotional management in a stressful world.  Begin to see tantrums as a great time to help a child learn to achieve calm and self-soothing.  It will take a while, but can give results that last.
  10. Play/playfulness/humor – play can benefit mind, body and spirit.  Losing oneself in a playful activity is rightfully called “re-creation” or an important way the person builds and creates the conditions of health. Healthy play is not stressful, intensely competitive or driven, but it is characterized by enjoyment, connecting actively with the surroundings and has no particular goal other than fun.  One of the best indications a child is at play is a smile on the child’s face.  If a child is playing to win something then a smile will often be absent.  Laughter is a major stress reliever and should be encouraged with children.  The family home must be a place to have fun; plan a family fun night with games, treats and let children plan the activities.

Mental/Neurological

  1. Functional internal working model – how we perceive the world determines a great deal about our experience.  Our mental model tells us what is happening, what to expect and how to understand and feel about it.  Developed early in life, this internal model can be problematic after a difficult childhood but can be changed with repeated positive experiences.  Determine what you believe the child’s model of self is and what you would like it to be.  You have a better chance to get there if you know where you want to go.
  2. Growing access to higher reasoning brain involvement – the amazing capability of the brain is only as good as putting it to use.  The upper frontal region of the brain is where many of the most important higher reasoning areas are found.  Teaching children to self-regulate, delay gratification, control emotions, consider options and plan their actions are all ways to exercise higher reasoning centers and promote growth in this important brain area.  Play some music and ask the child to describe the feelings that come up, show a movie and discuss it afterword.
  3. Challenging mental activity/academic growth – since we now know that our brain’s change throughout life, we also have learned that like other parts of the body we need to exercise our brain for maximum performance and health.  One of the main ways the brain grows and changes is to be challenged, with the most beneficial activities being difficult mental challenges that are different from any previous activities.  School is one place but not the only source of academic growth.  Have your child teach you something they know a lot about, we learn the most when we teach a topic to others.
  4. Active imagination – the human brain, particularly of a child, does not like inactivity.  Early abuse or neglect can harm the ability of a child to dream and imagine positive thoughts.  Imagination can be encouraged by play, reading stories, fantasy movies and encouraging the young person to tell stories.  Imagination is a mental activity that helps exercise the healthy brain.   Be sure to reinforce times your child uses imagination.
  5. Focused attention/meditation – bringing the considerable resources of the brain into a unified focus takes practice and, at times, instruction; but it has been found to be one of the key ways to encourage brain health.  Focused attention has many names, but it is the state of relaxation of the body with activation of the brain on something specific.  This activity helps with coordinating regions of the brain and developing neuro-networks.  Have the child show you a video game that they can play well to demonstrate focused attention, then play some soft music and teach the child to listen quietly with eyes closed and imagination engaged and then discuss the result.
  6. Coping/resiliency – stress is a part of living but it is the ability to effectively work with stress that separates health from disease (“dis-ease”).  Coping is the ability to handle stress in a healthy way and often comes with positive experience in overcoming stress.  Resiliency is the ability to bounce back after a difficult experience.  Fortunately, it is not how difficult the life experience is but the ability to handle it that determines coping with future stress effectively.  Point out how your child has overcome small and large challenges.  Catch the child coping and reinforce this.
  7. Perceptual clarity – our experience of the world begins with our perception of the situation.  Based upon what we perceive, we develop an emotional response and the combination of perceptions and emotions results in observable behavior.  If we want better behavior, we need to go back to square one and have accurate perceptions of situations, other people and of the self.  Initially you must provide clear perceptions for the child, you may think the child is not listening but the brain does listen and new neuro-networks are formed by your input.
  8. Developing intuition – the brain will naturally make judgments particularly when it comes to safety and to promoting self-interest.  Young children quickly learn how to get special attention from a parent by doing something cute.  Intuition goes the next step to pull together sensory input, combine it with past experiences, develop judgments and consider the motivations of others.  All these steps help promote an active brain with integrated internal communication.  Read a story and ask the child to consider what the person in the story was thinking.
  9. Healthy emotions – emotions are often characterized on a continuum from positive to negative.  Everyone would prefer the positive, but being healthy begins with the ability to experience the broadest range of emotional expression and to be on the positive end of the continuum most of the time.  Our emotions are influenced by our surroundings, but even more so by our perception of our surroundings.  Expression is how emotions self-heal after negative experiences.  Allow emotional expression and teach your child how expression is self-healing.
  10. Balance of past/being in the moment/future orientation – humans may be the only member of the animal kingdom who can live in the past, present and future.  However it requires practice to develop a balance of each.  It is important not to excessively brood over the past or have anxiety about the future that prevents the person being in the present.  Too much living in the moment can cause its own issues, so the goal is a balance.  Determine which of the three your child lacks and encourage more focus in that area.

Spiritual/Attitudinal

  1. Sense of connection to something greater than self – connection with others is synonymous with health because people are social animals.  Living with a sense of connection enhances health and a connection of spirit adds an overarching sense of meaning and purpose to living.  Model spiritual connection by sharing your beliefs with your child and encourage discussions and letting the child express opinions about principles of living.
  2. Optimism/positive orientation – because our outlook determines our experience, optimism is a pillar of a positive, proactive stance in life.   Finding the positive in any situation improves mood, outlook and even how effectively the physical body functions.  A positive attitude often equates to a healthy disposition.  Model optimism and reinforce signs of optimism in your child.
  3. Self-reflection/contemplation/prayer – there is much to discover in the stillness of our internal thoughts, but first a state of relaxation must calm down the racing mind of living in a busy world.  In the stillness of one’s thoughts can be found the origins of self and a personal guidance system that can make corrections to stay on course.  Most people use this calm state to connect with a higher power that helps guide the choices they make in life.  Turn off the TV and radio and have times during the day for the family to be internally still, together or separate.  This can establish a mental memory for the years into the future.
  4. Joy/personal contentment – joy is the state of being brought on by appreciation, gratitude and happiness.  Joy requires that we focus on what is valued and held in esteem while letting in the emotions of being surrounded by what we value and love.  Personal contentment is the continuous state of experiencing happiness.   First you must have personal contentment, then share this with your child.  You may be the only model the child has to plant this seed.
  5. Gratitude – being thankful for what one has is one of the most effective ways to counter the stress that comes from what one does not have.  An attitude of gratitude has been found in research to be directly associated with personal contentment and happiness.  A grateful, happy person is also a spiritually healthy person.  Encourage children to think about what they have, they think about what they don’t have with no encouragement.
  6. Altruism/kindness/empathy – consideration for others is essential to social success, but thinking of others must be put into practice in acts of kindness.  People who help others are healthier and happier and have longer lifespans.  Acts of kindness are health providing to both receiver and giver.  Teach your child to give to others in time and resources.  Volunteer with your child, teach your child how it feels to give to others.
  7. Social connectedness – people need other people to work, to play, to pray and to grieve.  The greater our connectedness to others, the healthier we are if these connections are characterized by engagement, honesty and respect.  The quality of the connection with others is important, just being in the company of others may not be connection.  Encourage participation in sports, scouts, camps, church groups and other opportunities to connect and learn social skills.
  8. Ability to forgive – in a society so focused on fairness and punishment, the role forgiveness plays in our health is seldom acknowledged.  Everyone has unfortunate experiences and it is a part of the human condition to be hurt by others.  Research has shown that forgiveness is actually an experience of power and resiliency.  Children need to be taught to forgive and the best method is by the modeling of adults demonstrating forgiveness.  Forgiveness does not come naturally so teach your child how to go about forgiving starting with small matters.
  9. Respectful disposition – respect is the language of health, we must respect our bodies, our families, our peers and respecting nature is an expansion of giving consideration to all that is around us.  Respectful acts are behaviors, but a respectful disposition is an orientation to the others and the world we live in.  Children must experience respect from adults to return respect.  Teach respect of adults, peers, strangers, and those we may disagree with.
  10. Self-Respect/self-love – the golden rule actually starts with self-love because treating others as we want to be treated assumes that we want to be treated with respect.  To respect and to care for others requires self-respect.  This fundamental basis for a healthy, happy life cannot be forgotten.  Catch your child reflecting self-regard and self-respect.  We get more of what we focus on from children, be sure to focus on positive qualities more than negative ones.

Interventions

Normally what is expected when interventions are mentioned are specific behavioral steps to modify or extinguish a problem behavior by a child.  However, the principle of integrated treatment is that behaviors are symptoms and manifestations of a deeper level of concern that may not be addressed by targeting the symptom.  To give one example, fire-setting behavior by children is most often an indication of a need of the child that has nothing to do with fire.  Our treatment systems have moved in the direction of treating symptoms and even encouraging this approach.  Several treatments have been popular for a number of years that generally fit into a short-term, solution focused, managed care orientation that typically promise some level of symptom relief.  However, if the symptom is an indication of a deeper intractable problem, it may be necessary to provide more integrated treatment.  How will you know?  If short-term approaches fail to produce the desired result then consideration of a more integrated approach is indicated.

Integrated interventions are best accomplished by impacting every aspect of the client’s life.  For this reason intensive alcohol/drug treatment is generally an inpatient setting, and residential treatment for serious habitual behavior has distinct advantages.  Addressing all aspects of the child’s world may be easier in a residential setting but it can be done in an outpatient setting as well, it takes all the adults in the child’s life being on the same team.

Because mind, body and spirit overlap and impact each other, so do the best interventions for troubled children and adults.  An effective intervention can have multiple positive impacts.  However, the principle of synergy works both ways; trouble in one area often produces a cascade of problems.  Because of this it is difficult to get effective results if a child is treated only in one role or part of the child’s life.  An intervention at home will generally have better results if implemented at school as well.  Teaching respect at Sunday School will have more impact if the lessons carry over to the home.

The first step to developing interventions that take an integrated approach is to focus on the right problem.  This often means to take a more comprehensive view of the issue.  If a child has significant problems with transitions at school, the issue might be handling the stress that changes produce.  An integrated intervention would help the child with handling stress in multiple areas and not just transitions at school.  Here are a few examples of interventions that use an integrated approach:

Example 1.  Symptom – frequent emotional outbursts.  Deeper problem – Handling Stress.  Many problem behaviors have the root cause in the inability to self-regulate.  A variety of stressful experiences in childhood can produce a serious deficiency in self-management, in part due to a lack of development of the frontal regions of the brain.  An integrated intervention would focus on building the brain’s capacity to override reactive primitive brain regions to enable self-control and self-regulation.  It sounds complicated but this can be done by teaching the child to relax.  It is important to practice relaxation because repetition is what trains the brain, and it is important to practice when the child is not in a state of high stress.  There are many ways to teach relaxation: sitting quietly, biofeedback activities, meditation, and many more.  Link a reward with practice because like practicing playing the piano, children give up easily if they are not good at a task.  Teach the child an internal signal to remember like a “Step 1, 2, 3 Plan,” #1 Stop and take a deep breath, #2 consider a bad and a good way to handle the situation, and #3 pick the good way when you are ready.

Example 2.  Symptom – demanding behavior with a lack of empathy for others.  Deeper problem – egocentricity caused by past negative experiences.  It is not just children who are egocentric and care mostly about their own needs; many adults have never fully learned reciprocity or the fundamental aspect of a relationship being a two-way street.  Children must be provided with everything when they are very young, but gradually they must be expected to give back more for what they receive.  This does not include basic needs, but it does include most everything else.  Reciprocity does not come naturally and must be taught and expected as an important life lesson.  Some adults struggle with expecting something in return from children, but giving the child a message that little is expected for what they receive could actually hinder the child in the long run.  Reciprocity is best taught by including it in all aspects of the child life: home, school, relatives, etc.  Reciprocity could mean that a ride to soccer practice might be preceded by giving Mom a hand with a family chore.  It might also mean getting a requested expensive name brand clothing item would expect a financial contribution by the young person.  The message of giving as well as receiving in relationships is a very important lesson to be learned as early in life as possible.

Example 3.  Symptom – breaking rules and/or not telling the truth and not taking responsibility.  Deeper problem – poor moral reasoning starting with the need to learn responsibility.  This is another area that does not come naturally with children and must be taught and expected as the child matures.  Young people rise to the expectations of the adults around them and holding high expectations for responsible speech and behavior is recommended.  Children learn best by example and one of the best ways to teach responsibility is by providing a consistent example of responsible behavior.  When a child falls below expectations, it is important to separate the child from the behavior and correct the behavior by discipline rather than by punishment.  To discipline means to teach a more appropriate response.  An excellent way to teach a behavior is through reinforcing approximations and find aspects of the behavior that can be reinforced rather than focus on what is not yet meeting the expected standard.  When a child misses the mark with a behavior, the adult should expect that the child take responsibility and do better.  Find some aspect of the child’s response that is acceptable and praise the child for this and expect the same effort in other areas and keep the expectations high.  The earlier the training in responsibility is implemented, the faster responsible behavior becomes a habit rather than irresponsible behavior.

Summary

Although it seems fashionable to focus on short-term, symptom targeted interventions, it may be wiser to consider the long-term through integrated interventions that target the overall child.  When done effectively, not only can there be symptom reduction but there are other gains that can be realized.  Integrated interventions acknowledge that individuals are complex and multiple factors interact with any problem, and solutions should address multiple dimensions of the individual to be most effective.  It may be cheaper and quicker to simply focus on external symptoms (like repairing the rearview mirror after an accident), but the benefits of integrated treatment can be shown in the short- and long-run to have the greatest impact in helping a child function with successful thoughts, emotions and behaviors as a child setting the stage for a more positive future.

Where to get more information on treating the whole child

Neurological Reparative Therapy, a Roadmap to Healing, Resiliency and Well Being.  (2011). D.L. Ziegler, Jasper Mountain, Oregon.

Traumatic Experience and the Brain, A Handbook for Understanding and Treating Those Traumatized as Children, Second Edition.  (2011). D.L. Ziegler, Acacia Publishing, Phoenix.

Beyond Healing:  The Path to Personal Contentment after Trauma.  (2009). D.L.Ziegler, Acacia Publishing, Phoenix.

Achieving Success with Impossible Children:  How to Win the Battle of Wills.  (2005). D.L. Ziegler, Acacia Publishing, Phoenix.

Raising Children Who Refuse to be Raised, Parenting Skills and Therapy Interventions for the Most Difficult Children.  (2002).  D.L. Ziegler, Acacia Publishing, Phoenix.

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Understanding and Treating Attachment Problems in Children: What Went Wrong and How Problems Can Be Fixed

By Dave Ziegler, Ph.D.

This somewhat complex article reviews the basic tenets of traditional attachment theory and describes both its strengths and weaknesses. Revisions to attachment theory are suggested and detailed explanation is provided of both the causes and treatment of various types of attachment problems. It is both a technical road map and a practical guide to the journey.  Although complex, It has been written to be understandable to professionals and parents alike. (31 pages)   Link to full article here.

Neurological Reparative Therapy: The Treatment Model of Jasper Mountain

By Dave Ziegler, Ph.D.

It is the human brain that enables individuals to adapt to the world either in optimal or destructive ways.  The choice of a positive or negative direction of adaptation depends on a variety of factors related to both nature and nurture.  The nature element includes epigenetics or the genetic codes that lay dormant or become operational.  The nurture involves the influence of the environment, which is substantial particularly related to adaptations to maximize safety.  Most mental health therapy must take on the challenge of facilitating modifications of the brain’s negative adaptations that take the form of cognitive patterns getting in the way of a functional life.  Effective therapies make an impact at the operational level of the brain, which includes individual neurons and neuro-templates (families of neurons that perform a function).

Altering the brain’s cognitions at the most basic level involves impacting the cellular neurology of brain development.  Psychotherapies attempt to change cognitions or what could be called cognitive mental maps or inner working models.  Both terms describe how the brain understands the conditions of the environment it operates in.  How the brain perceives a situation says a great deal about how it responds. Another way to change the brain is through pharmacological interventions that change the brain on a chemical level, specifically the neurotransmitters of individual neurons.

When the brain is allowed to develop optimally it strives for positive adaptations to the challenges of daily living.  However, when trauma or deprivation become part of the individual’s experience, the brain makes radical adaptive alterations focused primarily upon surviving rather than thriving.  These negative adaptations become the symptoms of most mental health problems such as: anxiety, depression, fear, hypervigilence, trouble connecting with others due to mistrust, inability to properly read social cues, addictions, aggression, and a large variety of behaviors associated with the autonomic fight or flight response to stress.

The brain’s primary function is to promote the survival of the individual. An important additional function of the brain is to successfully negotiate the world it finds itself in. Successful mental health treatment involves the repair of the brain’s adaptive functions and optimal neurological processes to put more focus on thriving and not just on surviving.  Brain research has found that the malleability of the brain works both in causing problematic symptoms due to negative adaptations as well as creating the conditions of health and self repair through the right external guidance.  Such support and assistance from the outside forms the core of Neurological Reparative Therapy.  This is a research based approach to making positive changes in the thinking, emotional expression and behaviors of young children.  It can be described as the facilitation of nerve functioning to optimize integrated cognitive processes, thus an approach that impacts the refocus of brain systems on positive adaptations to self, others and the world the individual functions in.  This approach is less an intervention than an orientation of holistic, ecological and environmental conditions needed to return the brain to its natural state of optimal adaptive functioning.  Brain research has identified that unless damaged in some way, the brain strives for success and even happiness in life.  Once damaged, the brain often needs external intervention to move beyond becoming stuck in negative patterns or putting exclusive focus on survival and reactivity to stress.

The Ten Fundamental Premises of NRT

The ten premises include both goals of this approach and steps that must be integrated into the treatment process.  The first five premises are goals and the last five are intervention steps. Each goal and step will be explained in brain terminology and then in more practical language:

Five Goals

The Five Goals toward neurorepair are general in nature and are not necessarily sequential as the steps that follow the goals.  One or more of the goals are addressed in each step of the process.  The combination of the goals and steps constitute the ten premises of NRT.

1.   Facilitate perceptual changes of self, others and the child’s inner working model

The individual’s experience in life is directly connected to his or her perceptions based upon the inner working model or how the person views self and others.  Based upon the individual’s perceptions the cognitive mental maps plot a course the individual will take including emotions and behaviors.  The first goal is to impact perceptions through altering cognitions in order to provide a more positive and optimistic orientation rather than a negative and depressive mind set.  Therapeutic work is directed toward developing a sense of self efficacy and helping the individual view others as resources for support and assistance.

The individual must experience some successes, however small they may be in the beginning.  The person must experience making a positive impact, having some positive influence on others, and is helped to begin to see the world as a more friendly and supportive place.  An example would be to help a child see school as a fun place to learn rather than a scary place where social and academic problems produce failure.

2.   Enhance neuro-integration

Executive functions of the frontal lobes of the neocortex require integration of functions in all parts of the brain.  Neuro-integration is the brain’s ability to access component parts to be integrated into an understandable whole that promotes good decision making.  Enhancing neuro-integration is also strengthening the hemispheric communication between the left (logical, analytic, verbal) and right (intuitive, artistic, emotive) hemispheres of the brain.

In the beginning the higher order thinking must come from the outside, from supportive people.  The individual must learn to combine the logical and emotive regions of the brain through activities that simultaneously involve both hemispheres of the brain.  For example, having a child listen to music and seeing a mental image (right hemisphere) while describing the image (left hemisphere).

3.   Alter the region of the brain’s processing information system

A primary goal of all psychotherapy is to promote functioning of the higher reasoning centers of the brain.  Many traumatized individuals primarily use the limbic region of the brain in daily life.  This region contains the brain’s fear center, as well as traumatic memories and emotional response system.  Combining these factors produces an individual reacting with fear and emotionality to reminders of previous negative experiences.  The much more functional alternative is for the higher reasoning centers of the neocortex to access information from all aspects of the brain and process the information to inform decisions and choices.

The individual must learn to think first, feel second and act third and not the reverse order.  The reactive limbic region of the brain cannot be the primary part of the brain used.  The person must learn to act rather than react in all areas of living.  For example, teaching a child when frustrated to go through a process such as – stop, take a deep breathe and make a request.

4.   Facilitate Orbitofrontal Cortex activation

The optimal goal of brain processing is to activate the Orbitofrontal Cortex in the frontal lobes of the Neocortex.  It is this complex part of the brain that accesses information from all other parts of the brain and enables deliberative and proactive mental activity.  This is the opposite of the reactivity of the limbic brain region.  This region of the brain can be viewed as the chief executive officer because it is the most complex and potentially productive neurological process that can result in effective consideration, planning, goal setting and accurately perceiving challenges, all of which are higher order executive functions.

Over time the goal is to have the individual process most information in the most advanced area of the neocortex.  It is this region that optimally provides goal setting, delaying gratification, moral and ethical reasoning and empathy for others among many other executive functions.  Every intervention that promotes thoughtful consideration, exercises the Orbitofrontal Cortex.

5.   Neuro-template development through repetitive practice

Networks of communication in the brain are made possible by neuro-templates and their individual component parts—neurons.  Neurons have a use dependent developmental process where neurons that are frequently used become larger and stronger as well as do more work and do this work faster.  In contrast, neurons that are never used may atrophy and die, and if seldom used they gradually deteriorate.  One key goal of exercising the brain is repetition, since it is in repeated use that neurons and neuro-templates, composed of millions of individual neurons, get more frequent use.  The more use, the stronger and more capable the brain functioning.

The expression ‘practice makes perfect’ refers to the importance of repetitive efforts to improve the results.  The brain changes gradually over time through the repetitive use of families of neurons that help us to do daily tasks such as: play the piano, type on the computer, or hear critical feedback without reacting with anger.  The more practice the brain has, the more the brain changes.

Five Steps

The Five Steps toward neurorepair are outlined below and provide a process where each step builds upon another.  It is important that each step occur in the proper order to enable the process to build in an optimal healing fashion.

1.   Assess the extent and causes of neurological impairment

All information available should be used to determine the extent of neurological impairment as well as the primary causes.  Traumatic events are the most common causes of serious impairment.  It is not essential to use complex medical scans to identify impairment.  Most problem areas have identifiable symptoms that point to both the level of intensity and the causal factors.  A good evaluation and history will normally provide sufficient information.  A variety of psychological rather than medical instruments are available to assist in the assessment phase.

Start at the beginning with a good assessment of history and current functioning in all areas.  There are a variety of formats and approaches to a good assessment and this model has room to approach this step in multiple ways.

2.   Identify specific cognitive, emotional and behavioral problematic symptoms

This is an extension of Step 1.  When specific problem areas are identified it is critical to accurately identify the right problem rather than the most obvious problem and consider the likely causes. Frequently with neurological impairment the representation of the problem area on the surface can look like an entirely different issue than it really is.  For example, the symptoms of ADHD are nearly identical to the observable impacts of trauma on young children.  To have the right problematic symptoms is important to be able to link these symptoms with the interventions in the next step.  This is the second part of the initial neurological assessment.

Insure that the initial assessment includes a careful focus on what the real issues are and what has caused them.  Only when we know the right problem do we have a chance at finding the right solution.  For example, most fire setters have problems other than pyromania (fascination with fire) such as needing attention, expressing a cry for help or reflecting unresolved anger.

3.   Implement interventions addressing the identified problematic emotional and behavioral symptoms

Once it is clear what the causes of the neurological impairment are, the next step is to design interventions that address the emotional and behavioral symptoms. Since behavior is an observable sign of the individual’s perceptual beliefs, or inner working model, cognitions are the focus of treatment as well as emotional and behavioral interventions.  There are many possible approaches that can be used for specific interventions including a large number of evidence based practices.

While behaviors are the most observable problem areas, they arise from how the child thinks and feels about everything in the environment.  The best way to make lasting change is to start with perceptions, and then move to emotional responses and the combination of these two result in externalized behaviors.  Interventions can include a wide range of approaches including many evidence based practices.  This model allows for a multiple of approaches to specific interventions.

4.   Decondition the child’s stress response cycle through multiple forms of relaxation and allostatic training

The most common problems associated with neurological impairment are the wide range of negative influences of neurological adaptations to traumatic experiences. A fundamental negative adaptation is hyperarousal and loss of self-regulation due to the stress response leading to a systemic fight/flight activation of the autonomic nervous system.  Research has identified that many forms of relaxation are the most effective tools to decondition the overactivation of the stress response cycle.  Allostatic training involves assisting the individual to return to a state of calm after arousal, which is the allostatic response.  Stress is a constant in life and the ability to self soothe and regain an inner state of calm is critical to handling the ever present stresses of life.

Reactions to stress are the key factors in emotional and behavioral problems.  Turning down the volume and learning how to produce a state of calm is the brain’s best weapon in the life long struggle with stress.  Find one or more of the many methods of relaxation that will fit best with each individual.

5.   Environmental enhancements promoting the building blocks of brain development

The most effective external impacts on neurological functioning are environmental in nature.  Every aspect of the child’s world should support the goals of enhancing neurological repair including: family, school, community, church, and youth activities among others.  Environmental supports should be in place to provide the building blocks of: safety, security, acceptance, belonging, trust, relationship, self understanding and personal worth throughout the environment the child is working within.  These building blocks enable the child to build personal growth on a predictable and solid personal foundation.

The individual either reacts to or asks for support from the world they experience.  The best interventions to produce the all important building blocks of social success are not individual, isolated and brief approaches, but instead are multi-faceted and coordinated approaches that involve all aspects of the individual’s world.  Environmental interventions for a child might include adjustments at school, at home, expanding involvement in community activities like sports/crafts/hobbies, assigning a mentor, or providing individual and family therapy.

Conclusion

Neurological Reparative Therapy has assisted Jasper Mountain to understand and help some of the most damaged and neurologically impaired children in our system of care.  Outcome data from our work has shown that the vast majority of children reduce serious external behavioral problems, modify emotional disorders, and after leaving our treatment the children usually get much better over time.  We believe these atypical results of intensive treatment are the result of significant impact on the brain’s processing system enabling the individual to successfully face the challenges and stresses of life.  Due to a change in the cognitive mental maps of the child, it becomes possible to rely on others rather than push others away.  Said another way, Neurological Reparative Therapy can return the brain to its natural state of health and thriving.

For additional information about Neurological Reparative Therapy, please refer to Dave Ziegler’s newest book Neurological Reparative Therapy: A Roadmap to Healing Resiliency and Well-Being.

A Residential Care Attachment Model

By Dave Ziegler, Ph.D.

Attachment disorder is much like many other issues in our society wherein we coin a new term for a very old problem and then scare ourselves about how bad it is.  Don’t misunderstand—an attachment disorder is a serious problem, but it is not what it has been presented to be by sensational stories and made-for-TV books.  Children with attachment disorders are just that—children.  They are difficult, yes; they can be hurtful, yes again; but they are not lost causes, much less developing Ted Bundys.  Our program works with these difficult children every day, and we see clear progress in nearly all of them.

There are tens of thousands of children in our systems of “care”, which means we have far too many children who have not been cared for where it counts—in their families.  These children often have defenses and tough shell that few can penetrate.  Without a knowledgeable and understanding care provider, this can lead to problems in reaching out and bonding.

These children have attachment themes rather than an attachment disorder.  Without someone reaching them while they are still more connected to family than to peer group (usually under the age of twelve), these children may well become the delinquents and criminals of tomorrow.  The halls of our prisons today are filled with the youngsters of our systems of care in the past.  For these children it is either pay now—with resources for social workers, therapists, and trained foster parents—or pay later—with free room and board in our institutions.  These children may well be the criminals of tomorrow, but they should not be confused with children with a true attachment disorder.

Children with a severe attachment disorder have never had a successful attachment to anyone.  Children with a mild to moderate disorder have had only partial and never truly rewarding attachments in their short lives.  These children start life in the first twelve to eighteen months with failure in the most basic of instincts in human beings—bonding immediately, first of all to survive and then to find a successful place in the interdependent world of other human beings.  When things go badly to begin with, the instinct to bond (promoting physical survival) is overridden by avoiding the pain and neglect of attaching (emotional survival).  The seeds of attachment are often sown long before the results are observed.  Without a disruption in the cycle of an attachment disorder, it may grow into a lifelong and unsuccessful search for a place in the social network of our society.

I believe we are still in a phase where as a society we are not sure how to help these children.  In our confusion and to some extent desperation, we have developed what appear to be desperate therapies, and some parents, professionals, and programs believe these intrusive approaches are all that can work.  I suggest that we take our desperation and first work to clearly understand the problem and its causes and then commit the necessary resolve and patience to test our solutions.  I would like to share with you one such patient testing ground, which is a small residential treatment program called Jasper Mountain Center.

How Jasper Mountain Started

 The center was founded by three babyboomers who were raised by their own families with varying levels of health as well as dysfunction.  Armed with college degrees, professional experience and seemingly unlimited energy, the three of us set out to make a difference in the world, following the advice of Mother Theresa—one person at a time.  The goal was to create a seamless integration of our home life and our professional work.  This goal was quite effectively reached, and we are not clear to this day whether this has been as good for us as it has been for the program’s children.  The practical steps are easy enough to recount:  endless meetings to determine the criteria to find the healthiest place in the United States to live, moving to the promised land in southern Oregon, and purchasing a rural ranch.  After six months of acclimating and very long days fixing up the old ranch, we informed the state child protection agency that we were ready for their biggest challenges.  The reaction from the state’s workers was one of equal parts elation and suspicion.  Elation that people interested in accepting very disturbed children into their home would also be experienced professionals with counseling backgrounds.  And suspicion as to why people who had a choice would want very disturbed children in their home!  Many years later there are those who still have suspicions.

Jasper Mountain Center was founded in 1982 on an eighty-acre ranch southeast of Eugene, Oregon.  The scenery was beautiful enough, with two major rivers, heavily wooded forest, waterfalls, an artesian spring, miles of hiking trails, and sheer cliffs rising to a thousand-foot mountain, all of which were on the property.  The ranch even had history as part of the second homestead in this region of Oregon and the end of the Oregon Trail for Cornelius and Jasper Hills.  To this beauty and history we worked to bring hope to some very confused and abused children.  From the beginning the children came to Jasper Mountain telling their stories of abuse and pain.  The program quickly turned its focus to healing the scars of sexual abuse, which were present in almost all the children.  We soon saw that some children healed very differently from others and that some didn’t seem to heal at all.  Of all the children, there were those who didn’t look at you, would push away any affection, and were quick to use and abuse you as they had been themselves.  In the early 1980s we began identifying children who had bonding problems, and invariably they were the most difficult of our difficult children.

How the Program Works

Jasper Mountain is based on principles of health in body, mind and spirit.  The program ensures clear air, clean water, plenty of exercise, and treatment components in a context of family where the parents are professionals.  This family focus has turned out to be the most important ingredient in the therapeutic stew.  Not that being in a family makes much difference to attachment-disordered children, but in the final analysis it is the ability of the family and its staying power that will make the difference in the bonding process.  In the early years the three of us did everything without outside help.  At this point the program has the state’s highest classification for supervision and treatment which requires one staff for every three children.

The program uses four basic categories of intervention:  environmental, behavioral, psychotherapeutic, and self-esteem.

  • Environmental intervention creates a therapeutic Disneyland, but rather than the happiest place on earth, we strive for the healthiest place on earth.  There is close scrutiny to every environmental aspect of the program, from the architecture of the buildings to diet, and from the amount of natural light to the control of violent themes that reach the children from the outside world (e.g., having no commercial TV).
  • Behavioral interventions include the mundane but important behavior management systems wherein the children earn levels that determine privileges.  At Jasper Mountain the children have a behavioral system for the residence and another for the on-site school.  Although the level system is the most traditional part of the program, the children get up each morning and go straight for the chart to find out what level they are on for the day.  Modifying behavior is an important step, but is only a beginning step in treatment.  Behavioral ways to require a give-and-take framework are essential with children with an attachment disorder.
  • Psychotherapeutic interventions include all the individual, group and family therapy interventions, as well as art and play therapy.  They also include occasional chemical interventions and sessions with the program’s psychiatrist.  Each child has an individual therapist in addition to our psychiatrist to promote skills at developing relationships with various adults.
  • Self-esteem intervention is where some of the unique aspects of the program can be found.  These include a variety of routes to the self-worth of the child, including biofeedback, concentration and meditation training, therapeutic recreation, an equestrian program, hiking and rock climbing, jogging, gardening, visual and performing arts, computer competency, positive video feedback to enhance the self-image of the children, and many others.

But even with magical interventions like the above (and there is something that every child will find magical on this list), there is no guarantee that an attachment-disordered child will use any of these to heal his or her disposition toward others.  With this backdrop of our basic residential treatment program comes the specific approaches used for these challenging children.

 What Makes the Difference?

At Jasper Mountain we are often asked why children with attachment disorders who can strike fear into the hearts of parents, caseworkers, and therapists are not feared in our program.  And here is step one in making a difference with these children—they must not be feared or their controlling nature takes over.  Relationships with these children are often initially no less than warfare.  In this struggle for dominance, if the child wins, everyone loses, and if the adult wins, everyone wins.  I see it as just that simple.  Of course, how to win the struggle with these masters of control is not simple at all.  That we do not fear these children in our program may come from the fact that no matter how good they are, so far none has been able to win the control war at Jasper Mountain.  In most cases the children, who are usually very bright, realize within weeks that they may be able to control an individual staff person for a while but not the whole program.

Another factor critical to our success with these children is to work as a team and control all variables in the child’s life producing a unified approach.  In our program there is only a building change from the residence to the school; the approach and staff act in unison.  We take time to work with caseworkers and family so that the methods the child has used to irritate, control and keep others distant do not work on campus or off.

Treatment with these children not only must strip them of their remarkably intricate insulation and defenses but also must provide a real and attractive alternative.  How can getting close ever look attractive to a child with an attachment disorder?  The answer is as simple as the first principle of negotiation—you get some of what you want only when I get some of what I want.  Despite attempting to look otherwise, these children want lots of things.  They are generally extremely motivated by material belongings, although they believe that if you knew this, it would make them vulnerable, and thus they pretend to be apathetic to almost everything.  Don’t believe it.  At the same time, they will take without giving if you let them.  You must teach them reciprocity and hold them accountable.  There must be a constant pressure to connect.  With normal children (has anyone seen one of these lately?) coercion is not a positive or useful approach.  But with these children they get dessert only after a polite request; they go to the movie only after doing a chore for you; they play fifteen minutes of Nintendo only after sharing two important events at school today.  The approach is clear:  You don’t get something for nothing (except love).

The effectiveness of treating these children comes down to every interaction between adults and the child.  This means that every contact between a program staff member and the child is a very small part of the puzzle but critical to the overall picture.  Manipulative children do not change if their tricks work on anyone.  If the therapist and parents work together but the school is out of the loop, and the child will never change, due to intermittent variable reinforcement, the same principle that brings confident gamblers to Las Vegas to lose their money time after time.  The child tells himself that he will prevail in the end.

As stated before, these children are usually quite smart, and when they understand that they must work to get what they want, here is their sequence:  First they start by not doing it, to see if you get flustered; then they do it halfway and grudgingly (punishing you); then, if they must do it right, they will do it with a bad attitude; and eventually they just do it.  These progressive steps occur only when they have to do their part to get what they want.  When this pattern is repeated over and over for years the psychological principle of cognitive dissonance steps in, whereby if your behavior changes, eventually your attitude must change and if your attitude changes, then our behavior must eventually change as well.

You must demand that children with attachment disorders do just what you want of them (which are progressive steps toward relationship).  They need not do it with an open heart or with honesty; they just need to do it.  What you begin to systematically show them is that they will not be abused when they are vulnerable and that the world where you get what you want by being close to others is far superior to using others and being emotionally and personally alone in the world.

The last factor that makes a difference is a four-letter word, time.  Time is a four-letter word in our culture because we don’t want to take the time to do most anything right.  We are irritated by the traffic light that delays us three minutes; we want the flu medicine that gives us fast, fast relief; and incredibly we are impatient when we have to wait two and a half seconds to store our documents on our old model computer.  Is it any wonder that we flinch at the prospect of taking years to treat an attachment disorder?  This may have something to do with the do-it-quick “holding” therapies that promise some bonding after an intensive weekend, or at least after the twelve-week special.  Some may believe that the patterns of withdrawal and distance in a true attachment disorder can be extinguished relatively quickly and a new pattern of interdependency and vulnerability learned soon after, but I do not believe there is any shortcut to the years of concentrated effort described above.  For the Star Trek generation, where any galactic problem is solved within the hour, years of effort are inconceivable, but they are truly necessary.

To be fair to all us parents who have a child with an attachment disorder in our home (I have one by adoption), we would have a better chance at putting in years of effort if only we saw some progress, even tiny successes, or at least the reassurance that we were heading in a direction other than futility and exasperation.  This is precisely what our program tries to give parents—a road map.  We all know that human beings that take at least twelve years to raise before the onset of their teen years.  Our current thinking is that the relearning process may take five to seven years.  I believe parents can learn to persist if they are shown a way that works, as long as they don’t get a false message that there is a quick fix.

The Jasper Mountain method works.  Whether it is the place, the people, approach, the time invested, or all of the above simultaneously.  The important thing is that the program wears the child’s defense down before the child wears the staff down.  We do not describe the children as “cured” when they leave Jasper Mountain.  Attaching is not only an instinct; it is also a skill.  We should not leave children in a rather scary and indifferent world without their defenses unless they are given new tools to succeed in the game of life.  It takes a very long time to learn how to bond even after the children decide they want to.  This is usually a process of unlearning and then relearning.  It is important that we not lead these children down this long road to healing if we are not prepared to go the distance.  In residential care this means that you never completely close a case.  Our program’s graduates keep in touch, come by, borrow money, and bring by their fiancé to meet the family.  We have invited our children into our extended family, and nearly all accept.

In adoptions we must understand that there may be no other chance for these children.  Due to the time it takes to free a child for adoption, to place the child in the right home, and to invest the five to seven years with him or her, there may not be time for a “Plan B” and starting the process over with another family.  This may sound like a great deal of responsibility for the adoptive family, but if real bonding doesn’t happen in the first adoptive family, it may never happen.

Perhaps the ultimate abuse is to take a child who is dependent on others for her very life, thwart her survival instinct by not placing her where she can form an attachment, fail to help her connect with others during her early years, and expect her to live the rest of her life emotionally and spiritually alone and separated from friends, a spouse, her own children, and even God.  It comes very close to a definition of hell, doesn’t it?  I hope you agree with all of us at Jasper Mountain that years of hard work are not too high a price to save the quality of life for a child with an attachment disorder.

Optimum Learning Environments for Traumatized Children—How Abused Children Learn Best in School

 By Dave Ziegler, Ph.D.

Introduction 

A great deal of attention has been given to our educational system and much of it has not been complementary.  Issues such as student progress, drop out rates, competencies in math, science and geography have all been the source of criticism and concern.  National initiatives have been implanted with reviews that have been more negative than positive.  Some have gone as far as to say that our public educational system in the United States is in chaos.  However, one area that has received little or no attention has been the ability of our educational system to meet the needs of children who are living with the effects of trauma in their past or present.  Some might say that the attention given to special needs children through special education services should address these children.  However, special education attempts to cover a host of causes related to learning difficulties and most of the time services focus only on the symptoms rather than on the problems themselves. 

Handicapping conditions that are observable such as blindness, physical disability, deafness, autism, and even dyslexia are much better understood in educational settings than emotional disturbances and learning disabilities that come from trauma in the child’s life.  For these children the answer is often a referral to the school counselor for the emotional issues that cannot be addressed in class.  But this separation of the emotional and the academic challenges faced by traumatized children is not getting the job done.  A child cannot compartmentalize emotions, thoughts, and behaviors as some adults can.  The whole child comes into the classroom and either succeeds or fails based upon whether all aspects are engaged in the learning process rather than impeding it. 

Some might say that a focus on traumatized children is spending valuable resources on a small group of children.  However, it is important that we learn from disciplines outside of education to get a better sense of the magnitude of the problem of trauma in our society.  It makes logical sense that the majority of children presenting for mental health concerns have histories of trauma.  After all, psychological problems must have some cause.  It may also be commonly known that the majority of incarcerated teens and adults have been abused and traumatized in their past.  Once again, it makes sense that an anti-social disposition toward other people and society as a whole must come from some damaging experiences in life.  It is less known that no less authority than the Center for Disease Control has determined that the primary cause for physical disease in America is early childhood trauma.  According to the CDC, trauma is the primary cause of: obesity, addictive behavior, suicide, chronic employment problems, and the ten leading medical conditions leading to premature death in this country.  It seems that when one stands back and looks at all the representations of failure and not reaching one’s full potential in our culture, trauma stands out as the most significant common factor across settings. 

To those who consider the population of traumatized children in our educational settings too limited to receive significant attention, another look at the data is indicated.  Trauma comes in many forms from child abuse, life threatening car accidents to any serious life event that overrides the child’s ability to cope with the experience.  Every year it is estimated that 5,000,000 new children are added to this list of significantly traumatized children.  Of these children, up to 50% will develop long-term debilitating after-effects of the trauma, including learning problems in school.  Some of the most serious effects of trauma come from child abuse, or betrayal by adults who a child must rely upon for basic needs and even survival.  Of the children who are abused, 94% know the abuser and generally have to rely on the person for protection, producing what some have called the ‘ultimate betrayal.’  When all forms of abuse are considered (physical, sexual, emotional, and neglect) perhaps 1 in 3 children are victimized by abuse during their childhood years.  Not only is the population of traumatized children in educational settings not a small number, trauma may constitute the greatest cause of underachievement in schools. 

What is needed in education, when it comes to traumatized children, is to bring together the substantial new information on trauma, brain development and the causes and solutions to emotional disturbance that exists in psychology and psychiatry and to weave this information into learning theory and progressive academic strategies.  We need conceptual and practical applications of learning approaches and environments where traumatized children succeed rather than fail.  This document will attempt to provide a conceptual framework leading to practical implementation in our experimental learning settings. 

How traumatized children perform in educational settings and why 

Trauma and learning in school do not mix well together.  This is not to say that trauma does not result in significant learning for the child.  The child learns not to trust, learns to be anxious around adults, and learns to be vigilant of the motivations of others.  What a child learns from trauma negatively impacts learning in an academic setting.  If the goal is for a child to come into an academic setting ready to learn, ready to emotionally experience the enjoyment and excitement of discovery, then the effects of traumatic experience will hinder learning in a variety of ways. 

Many traumatized children fail in school, and failure can take many forms.  Children can externalize their difficulties in emotions/behaviors and find themselves in constant trouble and the subject of behavioral restrictions.  Extreme examples of this are children who attempt to get expelled from school thus eliminating the problem of having to face the many challenges of going to school.  Some children sit quietly and can dissociate (day dream) in the classroom and not learn.  An extreme example of the internalizing child is the one who pretends to be ill, doesn’t come to school, or when they are old enough drops out of school altogether.  There are many impacts of trauma that often block a child’s ability to learn in the classroom. 

Trauma produces hypervigilence in children.  This is a survival skill to the child in a setting where basic needs are not provided, but it is not a functional skill in school.  Hypervigilence is often viewed as distractibility.  In part this is due to the child focusing on aspects of the environment that are not part of the learning plan.  The child in science class who is watching the non-verbal messages of a larger boy, wondering about safety during the coming recess break, is not hearing the science lesson. 

Trauma produces serious self-regulation deficiencies.  Often viewed as the most pervasive result of trauma, the lack of self-regulation causes these children not to have the inner understanding, inner strength, or desire to monitor emotional and behavior reactivity to events around them.  This is often observed as intense emotional expression due to challenges in the classroom. 

For reasons that will be explained in the next section, many traumatized children have difficulty putting what they learn into context.  An example of this concept can be seen in the child who can connect the dots that are numbers but cannot see that the dots eventually form a horse.  Being able to put learning into context is an essential aspect of educational advancement.  It means little if the child learns that slaves in early American history were sad and oppressed if they do not understand that slavery was wrong and a violation of human rights.  The common expression ‘not seeing the forest for the trees’ suggests that the many facts, figures and ideas in school must be able to be integrated into understandable and usable information for learning to be sustained. 

Trauma impacts the ability to trust others.  A lack of trust often results in a child misreading the motivations of others, both other students and adult teaching staff.  Some children believe that a difficult learning task was specifically designed to harm them.  Other traumatized children believe that when they are chosen second rather than first, this as a statement of how the teacher values or believes in them.  With peers, these children often presume negative motivations when this is not the case.  Misreading the intentions of others makes it very difficult to find social success. 

In some ways the most important success a child needs in school is social success. School is the first place out of the family that a child begins to develop self-image and understands others and how to interact with the larger world.  A great deal of success in school comes down to the ability to get along with others and to form relationships that can help provide support.  If this first journey into the larger world outside the family ends in failure and conflict, the child’s view of the world can be quickly established in a negative context.  With this in mind, some of the most important learning opportunities in school are at recess, lunch, and in the hallways.  It is in these settings that traumatized children have the most difficulty in school. 

Expecting a child to give their full attention in the classroom is like asking someone who just received a very disturbing phone call to go on with their day unaffected.  The problem with both situations is the affects of anxiety on our ability to focus on the task at hand.  Our emotions are ready to provide us with critical information to inform our decision-making process.  However, our emotions can also run wild with fear and anxiety in situations we either do not understand or believe we cannot handle.  School can produce debilitating anxiety for the traumatized child resulting in the child’s lack of focus and inability to learn. 

Traumatized child often expect the worst and many times experience just what they expect.  In part this comes from the child’s experience that events seldom go the way the child would like and many times the child is powerless and victimized by events and people.  This can produce a negative expectation of experiences in school and a self-fulfilling prophesy of failure.  As the saying goes, ‘If you think you can or can’t, you are right.’ Negative expectations develop into negative self-esteem and the internal belief that internal personal power and interpersonal skills are insufficient to influence one’s life for the better. 

How the traumatized brain functions 

Each of the above issues that are the result of trauma develop and persist in the brain.  Since the primary function of the brain is to maintain and protect the survival of the person, the brain is seriously altered by trauma.  Because trauma by definition is a situation that is beyond the ability of the individual to cope, the brain views traumatic events as a threat to its primary function of survival.  The brain has mechanisms to address threat and these parts of the brain will directly affect the traumatized child in the educational environment. 

The most primitive part of the brain is the brain stem located at the base of the brain.  The brain stem handles basic life support functions such as respiration, circulation and temperature regulation, and all of these bodily systems function without the need for our conscious oversight.  The brain stem also controls the autonomic nervous system which impacts all the other life support systems of the body (heart rate, blood pressure, rate of respiration, etc.).  Input from the environment can increase life support functions of the brain stem, which can adversely affect both personal comfort and a state of relaxed openness to learning.  The brain stem functions can be deescalated, but only when overridden by the neocortex, which will be addressed shortly. 

It can be argued that the section of the brain that is most impacted by trauma is the limbic system in the middle of the brain.  The limbic system has several physical components, but overall it controls emotions, arousal, sexuality, and attachment.  The limbic system includes the amygdala, the fear center or the ‘smoke detector’ of the body.  Whenever the individual perceives a threat of any kind, the amygdala sends out an internal shrill warning signal.  A traumatized child will have such an experience multiple times in a school day, and at times, multiple times in an hour.  The limbic system also plays a major role in distractibility by letting in too much sensory information causing a processing overload.  Trauma impacts on the limbic system also come into play because trauma memories are stored in this part of the brain.  After trauma, all future sensory input will be filtered through memories of trauma.  Such sensitivity can have ominous implications in a school setting. 

The top of the brain and most complex structures are in the neocortex.  This is the region of the brain that educational instruction most often targets.  Here is where the brain not only analyzes information but controls receptive and expressive language development and use.  Most students will come to school ready to process what they learn in this region of the brain.  Traumatized children can have serious neurological roadblocks to processing in the neocortex. 

One of the most important neurological deficiencies after trauma is the impact on mental organization or neuron-integration.  All of the above brain impacts of trauma affect the ability of the frontal lobes of the neocortex to organize input into useable and meaningful information and decisions.  In particular one region of the brain is responsible for overall integration of information and decisions from all parts of the brain and this is the orbitofrontal cortex.  Trauma can significantly degrade the ability of the brain from collecting, analyzing and using information the child learns either in the classroom or on the playgrounds of school.

Elements to avoid in school settings 

Understanding the above impacts of trauma on a student coming to school more concerned about safety and survival than learning math facts, can help us redesign the learning environment for these children.  It is time to get practical and address the do’s and dont’s of a school that provides an optimal educational experience for the traumatized child.  The first place to start is what to avoid in the learning environment for these special children. 

Stress and anxiety – research has determined that for most individuals either too much or too little stress do not promote optimal results.  This is somewhat different for traumatized individuals, but the question becomes how much stress can a traumatized student handle.  The answer is very little without substantial support.  The optimal environment would eliminate as much anxiety as possible because of how anxiety triggers hyper-arousal in the brain, decreasing focus and attention. 

Teaching to the bell shaped curve – traumatized children will be on the low end of the curve and efforts to ‘reach as many as possible’ will generally mean these children will not be reached.  Teaching these children means a specific focus on just those children who are not gaining from traditional teaching methods. 

Serious atmosphere where laughter and enjoyment are rare or discouraged – adults generally view learning as serious work, children view the best learning situations as fun and enjoyable.  Since adults run schools, they tend to be serious atmospheres with excitement, laughter and high energy kept in check.  Serious settings give traumatized children the wrong message that there is reason to be fearful. 

Unsupervised communication among peers – children can be brutally honest and can also be intolerant and hurtful.  Unless adults monitor what traumatized children hear from their peers, the setting will not feel safe to the child. 

Learning through criticism – people do learn from direct criticism but this is not an optimal strategy for the traumatized child.  Criticism is often amplified to give the child the message that they are incompetent or worthless if the child has received this message from adults in the past. 

Uneven competition – competition plays a major role in our culture and in our schools.  Competition can be a good experience for all concerned but special attention must be given to traumatized children.  Fair competition is not always even competition.  If the child is bound to lose, regardless of whether the rules are fair, it is not even competition and will not have a positive result for the traumatized child. 

A constricting environment – what many adults view as methods to maintain order, structure or decorum, many children experience as constricting.  Traumatized children respond to restrictive and constricting settings by fight (acting out) or flight (shutting down) and daydreaming.  Constricting environments are experienced by these children as a message that there is no room for you to be yourself in this setting. 

Rigidity – similar to constricting settings, rigidity is experienced by traumatized children as an authoritarian, inflexible and ‘mean’ atmosphere.  Rigidity is interpreted by these children into negative messages. 

An environment that can be easily disrupted – if a classroom is easy to disrupt, it will ultimately fail to meet the needs of traumatized students.  If by being expressive, questioning, or even acting out the classroom grinds to a halt, the child will either attempt to exert inappropriate power and control over others as a distraction or the child will be fearful that adults can be overcome by children in the setting. 

Elements to enhance in school settings 

Expressive learning – children best learn by doing, not listening or even watching.  Traumatized children bring into the classroom many fears and emotions as well as poorly self-regulated excitement and activity levels.  Expressive learning channels mental, emotional and behavioral energy into learning. 

Predictable structure – while avoiding rigidity, the optimal learning environment for the traumatized child must have comforting structure that signals to the child that safety is assured, adults are appropriately in charge, and students can focus full time on being interested learners in their own childlike fashion. 

More successes than failures – when people try something new they fail many times before they master the task.  Traumatized students give up long before the mastery stage and therefore decline or even refuse to take the risk to do something new.  The child must experience many more successes than failures in small and large ways. 

Adult mediated peer interaction – adults must monitor what is going on among the children because while ‘kids will be kids,’ the traumatized student will experience a lack of physical or interpersonal safety with ‘normal’ communication among children that is negative, teasing, bullying, or demeaning. 

External cognitive structure – instructors must overcome the brain deficits of traumatized children by providing the meaning, planning and connections from outside the child’s brain.  The adults must help the child understand the mental processing steps as well as the end result of higher order reasoning. 

The ‘unschool’ – most traumatized children have been in school before and many times it was a negative experience.  Since their brain filters new experiences through past negative memories, it may be helpful to shed the trappings of “school.”  The unschool looks different, feels different and is different.  What does the child experience walking into the environment?  Is there color, energy, interesting things, and space to be expressive, or is there rigid order, regimentation, posted rules and regulations and constrictions on movement and activity? 

Encouragement through relationship – traumatized children need social support but seldom know how to ask or how to accept such support.  Adults cannot wait until the child is receptive to relationship, the adult must meet the child much more than halfway.  Relationship with a safe adult addresses much of what the child needs in order to begin to open up to the risks of learning and trying new tasks. 

Teaching to the child’s individual learning style – children learn differently and the specific learning style of each traumatized child must be identified to help overcome the many hurdles to learning identified above.  Multidimensional instructional approaches that include auditory, kinesthetic, and visual components can be very effective. 

Even competition – as mentioned earlier, competition can be a learning tool if not overdone and if it is even.  Even competition ensures that any of the competitors have a good chance to win.  If the outcome is predictably determined, it may be fair competition but it is not even and will not be a positive learning experience for the traumatized child. 

Internalized goal setting – although mental reasoning must come from the outside at first, efforts must be put toward the child setting reachable internal goals.  The adults must insure that goals are not only reachable but are also successfully reached before the child can set additional goals.  When children with a losing attitude either win a competition or reach a goal, they seldom know how to handle this experience and initially can be tiresome and demanding of constant attention.  This is attention they need to make up for the past and they will need help to be a good winner and appropriately proud of an accomplishment. 

Enjoyment and fun – if learning is not fun then it will not be sustainable for the traumatized child.  The two primary jobs of a child are to learn and have fun.  It is optimum to do both at the same time when possible.  The optimum learning environment is learning in an enjoyable and fun setting. 

Variety of activities and help with transitions – the opposite of a constricting/rigid learning setting is one that has a variety of interests and activities.  Traumatized children are often poor at self-regulating high energy so they will need outside help even with positive emotional expression.  These children will also need adults to help them prepare for and initiate transitions from one activity to another. 

Choices in areas of the child’s interests – children will have more investment in learning things they are interested in and have some role in choosing.  With creativity, nearly any subject area can be learned through nearly any topic or interest the child has.  An optimum learning environment has room for the child to pursue chosen interests. 

Group/cooperative efforts promoting teamwork – because traumatized children live in a solitary world, positive social experiences are critically important.  These children will not initiate or even willingly participate initially in group learning, but this is a very potent and important way to gain social success and support.  Group efforts must be monitored closely by adults, encouraging of all participants and resulting in a successful outcome for the child to receive the optimal gain. 

School as the doorway to social and personal success in life 

For the traumatized child success in school carries more weight than for other students.  For these children school will either confirm that the world is filled with unresponsive, threatening adults and peers or these children learn that there are places that are safe, stimulating and even fun.  With the vast numbers of traumatized children in our society, it is time that we take a very close look at how to facilitate learning for these children.  One size does not fit all in education, particularly for traumatized children.  The time and effort put into developing an optimal learning environment has the potential to reap huge rewards for children who deserve the very best education we can provide them.  We may need to start small in this endeavor with limited experiments in centers of learning that show educational success with traumatized children.  Simultaneously, our educational system will need to take a critical look at the numbers of children who are being left behind with the educational system currently in place.

Understanding and Helping Children Who Have Been Traumatized

By Dave Ziegler, Ph.D.

The following are excerpts from Traumatic Experience and the Brain, A Handbook for Understanding and Treating Those Traumatized as Children.

There has been an explosion of new information on the human brain over the last fifteen years.  As our technology has improved, we have been able to study how the brain works in ways never before imagined.  This has lead to an avalanche of scientific research and exciting, although difficult to understand, professional literature on the brain–how it develops and how it works. These advancements have helped in many areas of science, but perhaps have been most helpful in understanding the mental and emotional problems that people develop.  This is especially true for children who have been traumatized.

The word trauma can refer to a wide variety of negative experiences—accidents, painful medical procedures, or life changing emotional events; but by far the most common traumatic experience is some form of abuse such as physical or sexual abuse or serious neglect.  Because of the impact of trauma on the developing brain, new advancements in understanding brain functioning have opened new doors to understanding children in our foster and adoptive homes.

As a psychologist and researcher, I am just like you, I can’t get lost in complicating medical and neurological explanations.  I just need to know the answer to one important question, “So what?”  What should I know and what should I do differently based upon all these new studies and all this new scientific information coming out on the brain.  I have spent several years asking this question, and I now share some of the answers I have found, particularly with parents who can use the information to help their children.

The human brain is the most complex organism in the known universe.  It is comprised on 1,000 billion individual brain cells (neurons) that develop 1,000 trillion connections with each other.  An infant at birth has a brain that is only 25% developed, which enables the child to adapt to a wide range of environments.  The brain of a child who is cared for by a loving family will adapt very differently than a child who has a drug addicted mother in a home where domestic violence is common.  We have learned from new research that positive and negative experiences not only are stored in the memory areas of the brain, but experiences also sculpt the developing brain and determine how it will process all new information.  This process goes on at every age even before birth, and just because a child does not have conscious memory of an event (explicit memory), does not mean the brain does not remember (implicit memory).  “So what?”  Well, this helps us see that the earliest experiences of a child will not only be carved in the brain’s memory but the brain itself will develop differently because of the environment.  The brain develops in predictable ways to experiences.  The loving supportive environment produces larger more well developed brain structures that will help the child be smarter, be more inquisitive, and feel safer allowing the brain to put less energy into self protection.  If the child comes into a world with trauma of any kind, the higher regions of the brain grow smaller affecting the child ability to learn and fully understand the world other than how to survive by being ever vigilant of possible harm.

The brain has many complex components, but basically it can be divided into four areas.  The brainstem is at the base of the brain and handles the less glamorous but essential functions such as breathing, heart rate, blood pressure, temperature regulation and respiration. The diencephalons includes several parts of the brain and controls motor regulation such as walking and balance as well as appetite, sleep patterns, and the memory to ride a bike even after years of no practice.  The limbic system is fundamentally impacted by trauma.  It controls emotions, perceptions, attachment and sexual behavior.  All memories of trauma are stored and impact the individual in the limbic system, but these memories are for the most part unavailable for conscious recall.  The last and highest region of the brain is the neocortex.  This is the largest part of the brain and controls the personality, goals, decisions, and what makes a person a success or a failure in life.  The difference in the overall functioning of the brains of Adolf Hitler and Mother Teresa was minor, but the neocortex produced very different people.  “So what?”  A traumatized child operates from the limbic system and doesn’t understand why they act as they do.  The goal is to provide safety the child experiences so they can operate and develop the higher regions of their brain—decision making, learning from the past, developing values, and forming a personality others care to be around.

The primary job of the brain is survival.  If survival is threatened, the rest of the brain shuts down except for functions that help self-protection.  The brain adapts throughout life, but the strongest adaptation is within the first two years of life.  So what?  Early nurturing care for a child makes a lasting difference as does early abuse of a child.  However, the brain continues to adapt to the environment, so ingrained patterns can be changed with consistent positive experience.

 The brain is made up of networks of neurons (brain cells) that communicate with each other.  If mommy is a caring, loving, nurturing experience for the infant, a strong neuro-network develops that says ‘mommy is good.’  If mommy is self-absorbed, unresponsive to the child’s needs when they cry and physically abusive to the child, an even stronger neuro-network develops that says ‘mommy is to be avoided’ to support survival.  So what?  To an abused child, mommy can be any adult in the role of care provider, which may include foster parent, adoptive parent, teacher, grandparent, etc.  The reason attachment is a common problem with many abused children and children in a foster or adoptive home should be clear.  The goal must be to develop new neuro-networks that have to do with safety, predictability, caring, and the child’s physical and emotional needs getting met.  Remember the brain literally changes with every experience.  It will continue to adapt in your positive, nurturing home regardless of how serious past abuse has been.  Yes, Virginia, there is hope!

More “So What’s”

  • Consider all problematic behavior within the context of survival to better understand ‘why he keeps doing that?’

  • Repetition is important because with every positive experience the impact on the brain grows.
  • Traumatized children expect the worst and focus on the negative.  If you understand this, you will be better prepared for it.
  • Childhood neglect is the most damaging trauma.  The child must not have basic needs threatened in any way or survival will be all they think about.
  • Do not allow radical therapies for traumatized children.  “Holding Therapy,” “Rage Reduction,” and other desperate approaches trigger the memories in the limbic system and make matters worse.
  • At the point the child was abused, the brain was focused on survival not learning.  The development the child missed due to abuse will need extra attention.
  • Traumatized children will often score lower on IQ tests than their true ability.  Retest when their environment is helping them heal and watch the scores go up.
  • The goal in healing trauma is not to keep the child calm.  The goal is when the child becomes agitated to help them learn skills to reduce the agitation.  This repeated cycle is what most helps the child.
  • Promote play with traumatized children.  Play is very healing to the brain and the emotions.
  • Don’t give up hope!  The human brain is capable of healing in ways we do not yet understand.  It may be a long road to healing and the child may not get there while still in your home, but every situation makes a difference.

The Therapeutic Value of Using Physical Interventions to Address Violent Behavior in Children

By Dave Ziegler, Ph.D. 

[Published initially in The Child Welfare League of America’s Children’s Voice, vol. 13(4) 2004] 

A quick review of the published information on physical interventions over the last three years would seem to indicate that a fundamental and universal shift has occurred, away from the use of therapeutic restraint, as well as the use of seclusion, to address violent behavior in children.  However, this is somewhat deceptive.  Treatment environments have been faced with increasingly violent and assaultive children in a continuing trend that was identified a decade ago (Bath, 1992; Crespi, 1990).  This challenge must be considered along with the fact that young children most often present violent behavior in treatment settings (Miller, Walker & Friedman, 1989).  Unlike the impression given by recent media, the reality is that most treatment centers for young children use physical interventions to address violent behavior in a safe and effective manner.  It is true that physical interventions have been the subject of substantial training to insure they are done according to national crisis management guidelines, but it is not true that the mental health community has abandoned physical interventions for violence.   

It is important to clarify the interchangeable terms therapeutic holding and physical restraint.  This physical intervention is when a trained adult stops a child from hurting self or others by using approved crisis intervention holds to protect the child until the child is no longer a danger.  There are a variety of approved holds but all of them restrain the child from being violent and causing damage to self or others.  A distinction must be made between the type of holding discussed in this article and “holding therapy,” which is a physically intrusive method to produce a crisis in a child and force the child to experience physical or psychological pain.  Holding therapy and other similar intrusive techniques are not sanctioned by any legitimate professional organization and in the opinion of the authors are not therapeutic and are not valid psychological treatment. 

There is increasing pressure on these programs to become restraint and seclusion free, but is this direction in the best interests of the children?  The answer will emerge only after a dialogue of the valid points on both sides of this issue, but to date only one point of view has been advanced.  The purpose of this article is to provide another perspective on this issue, one that has not been previously put forward. 

A variety of interventions have been used over the years to address violent behavior among children and adolescents (Troutman, Myers, Borchardt, Kowalski & Burbrick, 1998).  In settings such as psychiatric hospitals and treatment programs, two of the most frequently used interventions are therapeutic holds (also called therapeutic restraint) and giving the individual a chance to regain self-control in a seclusion or quiet room.  Interventions less often used to address violent behavior are mechanical restraints and using medications for chemical restraint (Measham, 1995).  Over the last ten years the latter two interventions, mechanical and chemical restraint, have been criticized as excessive and too restrictive.  Mechanical and chemical restraints have declined in some programs and have been eliminated in others, particularly in non-hospital settings. 

More recently, in the last three years, restraint and seclusion have been the subject of considerable controversy.  A host of arguments have been presented against the use of restraint and seclusion to address violent behavior in children (Wong, 1990).  Most notable was an investigative series in a Connecticut newspaper, the Hartford Courant (Altimari, Weiss, Blint, Pointras, & Megan, 1998).  This expose of injuries and deaths reportedly caused by the use of restraint and seclusion is often credited with starting the current wave of criticism for the use of restraint and seclusion.  This controversy has run the gambit from media coverage to policy change and new federal legislation. 

The array of criticism directed at the use of restraint and seclusion has one glaring absence, a review of the therapeutic benefits of physical holds to address violence among children.  Although seclusion is often used interchangeably for therapeutic restraint, the two are very different interventions bringing up very different issues.  The focus of this article will not be seclusion, but rather a review of the therapeutic components of physical restraint. 

Before addressing the potential therapeutic components of physical restraint, it is important to briefly consider the most frequent criticisms of using this intervention.  A recent nationally published article is a good example of the criticism being directed at the use of physical restraint (Kirkwood, 2003).  The article calls restraint violent, dangerous, and even potentially deadly to children.  The point is made that this intervention can actually cause further trauma due to concerns such as counter-aggression by adults and repeating abuse the child has experienced in the past.  Restraint is called a violent means to maintain control and “rule over” children.  Rather than use physical restraint, the article recommends negotiating with the child, understanding the reasons behind the behavior and giving the child choices.  Some critics have gone so far as to say a physical restraint should be avoided at all costs and any use of physical restraint is a treatment failure. 

In the face of such harsh criticism, is there any defense for physical interventions such as restraining violent children?  The authors believe there is, but the starting point of discussing the therapeutic components of physical restraint must begin with an acknowledgement that even good interventions when done poorly, or at the wrong time, lose some or all of their therapeutic value.  Rather than an indictment of all physical interventions, the criticisms outlined in the article mentioned above can serve to improve the quality of physical restraint and, for that matter, all other behavior management.   

All behavior management can become ineffective, demeaning and even psychologically damaging if done poorly.  It is safe to say that using a violence intervention to “rule over” children is poor behavior management.  Like other types of behavior management, if physical restraint is done in a violent and dangerous way, it may be possible to replicate the past abuse of the child, at least in the child’s mind.  However, physical restraint is not step one of any intervention with a child.  Physical restraint should not be a shortcut to taking the time to understand the child and the reasons behind the child’s behavior.  Restraint is also not the opposite end of the continuum from appropriate negotiations and setting out clear and meaningful choices.  Physical restraint is properly used only when the adult is trying to understand the child and other limit setting techniques have failed to safely address the violent behavior of the child.  Interventions are also not therapeutic when they are based on a power struggle or when the adult is out of control.  Any behavior management approach loses its therapeutic value if used to merely control the child without supporting and understanding the child’s thoughts, feelings and goals for the behavior.  This is true for all behavior management interventions such as: time outs, logical consequences, giving choices, negotiating as well as physical restraint.  It is not necessarily the technique that makes an intervention therapeutic, it is more often the when, how, why and by whom the technique is employed that makes the difference. 

If physical restraint is a legitimate part of any behavior management plan, it must have the potential of therapeutic value when used appropriately.  Among nationally recognized crisis behavior management systems there are clear guidelines as to the appropriate use of physical restraint.  Behavior management systems such as Crisis Prevention Institute (CPI) and Professional Assault Response Training (PART) are two well known examples.  Both outline the safe and effective use of physical interventions after crisis de-escalation techniques have been used to address the situation. 

National accreditation organizations such as the Council on Accreditation (COA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) sanction the appropriate use of physical restraint.  If any legitimate organization were to declare physical restraint a “treatment failure,” an expression currently being used by opponents of physical interventions (National Technical Assistance Center for Mental Health Planning, 2002), one would expect it to come from entities that hold organizations to the highest standards of the industry, and yet all major national accrediting bodies sanction the use of physical interventions.  It is difficult to find any national professional organization, such as the American Academy of Pediatrics, that does not agree with the general statement, “Restraint and seclusion, when used properly, can be life-saving and injury sparing interventions” (American Hospital Association and National Association of Psychiatric Health Systems).   

Here are some of the reasons why physical restraint, when done well, can be an important, effective and therapeutic intervention to address the violent behavior of children. 

  • Physical touch can be very therapeutic to children, particularly in a crisis. Long before a child learns English, Spanish or Swahili, the first language a child learns is the language of touch.  Touch is considered a basic need for all children.  When a young child is frightened, the first instinct is to hold on to a trusted adult.  Children who demonstrate serious acting out often do not know how to ask for what they need, yet supportive, firm, and safe physical touch can give a child a message of reassurance.  If touch is poorly used, such as slapping or striking a child, the message of such a touch can be very frightening.  When a young child is in a crisis situation, touch can be one of the most reassuring interventions when the touch lets the child know that the adult will insure the situation will be managed safely for everyone.
  • Emotionally defended children can become psychologically more real and available after an emotional release during a physical restraint.  This dynamic is not restricted to children.  It is often when our emotions overwhelm us that we open to learning something new that we have defended ourselves from.  There is a parallel in psychotherapy to this dynamic when a client has a difficult but insightful experience that usually includes being catapulted beyond the individual’s ability to keep out important information.  For some children it is difficult to get to this place without some form of emotional meltdown that often accompanies a physical intervention.
  • Children need to know the adult will insure everyone’s safety.  The adult is responsible to insure the child cannot hurt him or herself or others, if other management methods fail, physical interventions are important.  The adult cannot put the responsibility on a child to regain inner control once it has been lost.  The amount of time it takes for any crisis situation to be under control, during which time chaos reigns, is the amount of inner fear the child has.  Children can regain their footing, but the assistance from a supportive adult can be critical.
  • Young children with emotional disturbances need and often seek closeness with adults and violence is less threatening than other forms of intimacy.  Behavior cannot always be taken at face value with children who experience violent rages.  In fact, these children can often act counter-intuitively.  They can push you away when they want closeness, they can strike at you when they are beginning to care about you, and they can act in ways to receive reassuring touch by becoming aggressive and violent to self or others.  It is important to understand why a child is acting the way they are.  At times, a frightened child seeks and needs the reassurance of physical touch when they can’t allow themselves to ask for physical comfort.  It is often trusted adults that young children become violent with, because they know they are safe and they will get the reassurance they need.  If they do not find the physical reassurance they need and seek, they will often raise the level of acting out until they get it.
  • Physical restraint is the surest and most direct way to prevent injury and significant property damage when the child loses control.  The above referenced article in Children’s Voice (Kirkwood, 2003) begins with a description of a child doing significant damage to a car with a rock.  In this example the adults stood by and did not stop the child and the author called this a better, however more costly, intervention.  This seems to defy common sense.  Would any parent stand by as a child does thousands of dollars in damage to the family car?  Recently, a child in our program picked up a rock, ran around a new car and heavily scratched it to the amount of $2,650 damage.  Afterward the child felt badly for such out of control behavior and said good kids do not do such bad things.  It is important to understand that kids, as well as adults, view themselves in relation to their own behavior.  It only makes sense from a practical and therapeutic perspective to stop children from hurting others and doing damage they will use to feel worse about themselves.  Physical interventions may be the best way to insure this. 
  • Traumatized children must learn that emotionally charged situations and all physical touch does not end in being used or abused.  The human being has several types of memory, including factual (explicit), subjective (implicit), emotional, experiential and body memories (Ziegler, 2002).  Early experiences of touch can establish a lifelong trajectory of meaning attributed to physical touch.  It is common that children with emotional disturbances have difficulty with caring touch.  Body memories need to be addressed while the child is still young or the child can avoid the very closeness they need.  Abused children learn that when someone gets angry someone else gets hurt.  Supportive physical restraint retrains the body not to fear touch from others. 
  • An intervention considered to be good parenting is likely to be good psychological treatment.  Psychologists, family therapists and parent trainers would all call stopping a child from running into a busy street good supervision and effective parenting.  They would also recommend a parent prevent an older and much larger sibling from physically harming a younger sibling.  It is not hard to imagine the same parenting consultants suggesting that when an angry child is heading for the family car with a baseball bat, that the bat be taken away before the damage occurs.  If these parenting interventions would be basic common sense to most everyone, why would some call these same interventions unhelpful and non-therapeutic to children with serious anger problems?
  • Children with emotional disturbances need the assurance that adults are safely and appropriately in control of the environment.  Serious acting out such as violence is often seeking this assurance.  Most emotional problems in children have their source in chaotic, abusive and/or neglectful home environments at some point in the child’s life.  To be in a home where the adults are not in control of themselves or the environment is like going down the road in the back seat of a car with no one driving, it is terrifying to a child who has been there.  These children often push a new environment to the point that the child finds if the adults can safely and appropriately manage the challenges.  Often when the child has such reassurance and can rely on others for basic needs, he or she can once again get back to the task of being a child.
  • Treatment programs are responsible for directly addressing violent behavior and not just skillfully preventing the behavior from presenting itself during treatment only to reappear in the home or community after treatment.  The argument that all physical restraints can and should be avoided at all cost may address the principle of prevention, but misses the point of treatment.  In the extreme, all physical restraints could be avoided, this simply requires an adult to passively stand by and allow a child in a rage to do whatever he or she wants to do.  One may call this “preventing” a restraint, but how did it address the responsibility of a treatment program to treat and extinguish serious violent and antisocial behavior?  The role of prevention and treatment are quite different.  Not intervening when a therapeutic response is called for is not so much prevention as it is abdicating adult responsibility.  If someone needed treatment for a debilitating phobia of spiders, the symptoms could be prevented by having an insect free environment, but this would not be treating the phobia.  Programs charged with treating violent behavior cannot simply insure that the symptoms never come up in the treatment environment because they will surely resurface once the child leaves that setting.  In psychological terms, treatment often requires steps such as re-exposure to stimuli, cognitive reprocessing, skill development, practice and mastery, none of which have an opportunity to happen if preventing symptoms or preventing a particular intervention at all cost is the goal. 

Are therapeutic benefits guaranteed by the appropriate use of physical interventions?  No intervention comes with a guarantee.  However, as one side of this debate offers sensational media stories and points to abuses of physical interventions (and there have been abuses), there exists research and professional literature that has found therapeutic value in physical restraint when used properly.  Restraint has been found to shorten the crisis over other interventions (Miller et al., 1989).  Research studies have found physical restraint effective in reducing severely aggressive behavior, self-injurious behavior and self-stimulatory behaviors (Lamberti & Cummings, 1992; Measham, 1995; Miller et al. 1989; Rolider, Williams, Cummings & Van Houten, 1991).  Physical restraint has been found helpful in treating aggression with dissociative children (Lamberti & Cummings, 1992).  Physical interventions have also been recognized in the role of re-parenting children who have not been taught limit setting due to absent parenting (Fahlberg, 1991).  Physical restraint has been called an effective intervention to protect the child and others from harm and prevent serious destruction of property (Stirling & HcHugh, 1998). 

A frequently cited criticism of restraint is that it takes away the ability of the child to learn and internalize self-control.  However, research studies have found the opposite.  In two studies nearly a decade apart, physical holding produced rapid gain in internal behavioral control (Miller, Walker & Friedman, 1989; Sourander, Aurela & Piha, 1996).  Physical restraint has been called ethically sound (Sugar, 1994) and recognized for significant therapeutic benefits (Bath, 1994). 

The arguments for and against the use of various interventions such as medications, institutionalization, physically intrusive therapies, seclusion, and physical restraint are important discussions.  However, children are not served when only one point of view is expressed.  Many interventions, including physical restraint, can have damaging consequences when improperly used,   however, at times the consequences of not using serious interventions can be even more damaging to a child.  A five-point evaluation of interventions for violent behavior has previously been recommended (Ziegler, 2001):

  1. Was safety insured?
  2. Was self control internalized?
  3. Was the intervention individualized and based on understanding the child?
  4. Was the intervention therapeutically driven? 
  5. Was the intervention effective in producing the desired  result? 

If we are to meet the challenge of increasing numbers of violent children in our system of care, we must carefully consider how we can best meet the short and long term needs of these children, while insuring the safety of other children, their parents, and the community at large.  A reasoned approach to this question would be careful consideration of all the issues and not a singular movement to reduce or eliminate physical interventions, which have been found to be safe, ethical, effective and therapeutic.  

References 

Altimari, D., Weiss, E.M., Blint, D.F., Poitras, C. & Megan, K.  (1998).  Deadly Restraint: Killed by a system intended for care.  Hartford Courant, Hartford Connecticut (8/16/98). 

American Academy of Pediatrics—Committee on Pediatric Emergency Medicine      (1997).  Pediatric, 99 (3), 497-498. 

American Psychiatric Association, Arlington, VA. 

Bath, H.  (1994).  The physical restraint of children:  Is it therapeutic?  American Journal of Orthopsychiatry, 64 (11), 40-48. 

Council on Accreditation for Children and Family Services (2002).  Accreditation Standards 7th Edition.  New York, NY. 

Crespi, T.D. (1990).  Restraint and Seclusion with Institutionalized Adolescents.  Adolescence, 25, (100), 825-828. 

Crisis Prevention Institute, Inc.  (2001).  Nonviolent crisis intervention Training Manual.  Brookfield, Wisconsin. 

Fahlberg, V.I.  (1991) A child’s journey through placement.  Indianapolis:  Perspective Press. 

Joint Commission On Accreditation of Health Care Organizations (1996).  Accreditation Manual for Hospitals:  Volume 1 – Standards.  Oakbrook Terrace, Il. 

Kirkwood, S.  (2003).  Practicing Restraint.  Children’s Voice, 12 (5), pp. 14-19. 

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