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:
- Personal self-care
- Nutritional intake
- Engagement in life skills of daily living
- Attachment/social skills
- Optimal sleep
- Activity and exercise
- Communication skills
- Pleasure and pleasurable pursuits
- Play and playfulness
- Functional internal working model
- Growing access to higher reasoning brain involvement
- Challenging mental activity/academic growth
- Active imagination
- Focused attention/meditation
- Perceptual clarity
- Developing intuition
- Healthy emotions
- Balance of past/being in the moment/future orientation
- Sense of connection to something greater than self
- Joy/personal contentment
- Social connectedness
- Ability to forgive
- Respectful disposition
- 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.
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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.
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.