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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Promoting Healthy Sexuality After Sexual Abuse

By Dave Ziegler, Ph.D.

(The following article is dedicated to a friend and colleague Jan Hindman, who enriched the field of sexuality and trauma treatment before her untimely death in 2007)

I need to make you uncomfortable for a bit, but it is for your own good and the good of the sexually abused child you are trying to raise.  I say this because I need to talk about S..E..X., the most difficult topic for nearly everyone to talk about.  But the problem is that we have to talk about it if we want to raise a sexually healthy child.  Why human sexuality is so difficult to talk about in polite company is a topic for another day, but our starting place is that most of us would rather face any other issue than sexual issues with our children.

If you have a sexually abused child in your home that you are trying to parent, then you have a challenge on your hands that not even the experts have been willing to directly address—how does a parent promote healthy sexuality for a child who has already had sexual experience in the form of abuse?  If you have attempted to find some good books on the topic, which you probably haven’t, you found that there are none.  Yes, you heard me correctly; there are many good books on most every topic related to sexuality except how the help a child develop a healthy view of sexuality after the very unfortunate experience of sexual abuse.   In part this is an oversight, but even more so this lack of resources for parents is symbolic of our collective cultural neurosis that the less said about sex the better (unless the task involves advertising).

I want to begin our discussion with a quote from my friend Jan Hindman who wrote in her last book, “Of course we love our children.  We teach them what they need to know.  But when it comes to sex, we do nothing and hope the Sex Fairy will zap them in the crotch when they walk down the aisle to get married and magically, they will turn into sexually healthy adults” (Hindman, 2006).  This quote sums it up pretty well for our culture.  We avoid sex education because it might encourage children to act in sexual ways.  We put off talking to our children about sex, “until they are old enough to handle it,” meaning when the child is seventeen and has learned all they needed to know from other sources such as peers or the media (both excellent sources of healthy sexual information, right?).

The principle barrier to our culture helping children to become sexuality healthy is that we deny the fact that children are sexual beings.  We have body parts that perform a myriad of functions, but it is only the sexual body parts of our children that we hope will lie dormant in the dark recesses of their bodies only to awaken with enthusiasm on their wedding night. Enough said about how messed up our culture and most of us are regarding sexuality, we need to change the focus to discuss how we can help sexually abused children have a chance at a life that moves sex from a curse to a blessing.

I have started our discussion this way because we cannot give to a child what we do not possess ourselves.  If we want to raise a sexually healthy child we need to have some measure of healthy sexuality ourselves.  If we want our children to have some comfort with the topic of sex then we must model comfort.  Alright, you may have to fake it a little.  But seriously, we need to start the process by looking inward at ourselves.  Consider the following questions and how you would rate yourself:

  1. Do I live in a way to acknowledge that I am a sexual being?
  2. Am I comfortable with my own sexuality?
  3. Do I value and respect this important part of who I am?
  4. Am I aware of the important part my sexuality plays in forming who I am?
  5. Do I act in harmony with my sexual beliefs?
  6. Am I respectful of the above in others?

As you read further, you will see that respect will be a cornerstone of our journey.  Few of us are statements of full health so we all have to start where we are.  However, we need to realize that with the difficult road ahead we need to first acknowledge, respect and value our own sexuality if we are to impart healthy sexuality with our child.  Here are a few general suggestions from the Advocates for Youth when it comes to addressing sex with all children:

  • Examine your own beliefs and values before teaching a child.
  • Assert your own personal privacy boundaries; decline to discuss private sexual behavior with the child.
  • Use accurate language for body parts and functions.
  • Discuss sexuality at times that work best for connecting with your child.
  • Clarify relationships and how people are related to others.
  • Use photos, pictures, and visual materials.
  • Use teachable moments that come up in daily life.
  • Be honest in answering questions.
  • Value the child’s feelings and experience.
  • Offer praise and support.
  • Repeat information over time as needed.
  • Take advantage of available resources.

One of the ways we discourage rather than promote healthy sexuality in children is to deny their sexual interest and curiosity.  Take a moment and ask yourself the following question–since my child is a sexual being what are the ways he or she can appropriately express this sexuality? We all know many ways children can be sexually inappropriate, but are there appropriate sexual expressions in your home?  If there are none, like most families, then you fit right into the prevailing culture, but your child will remain confused about sexual thoughts, feelings and behavior both internally and with others they encounter.  Remember that most sexually abused children have a heightened interest and sensitivity to sex, even if you don’t hear about it you can trust that there is a lot going on inside the child’s biggest sex organ—the brain.

Promoting healthy sexuality is more than a two-week plan of action and hoping your job is done.  Sexuality will come into play at every developmental age of the child.  The older the child gets the more complex it becomes, and the more vulnerable you will have to be to model being an “ask-able parent.” This meaning someone the child knows he or she can go to for answers to their questions and receive support for their confused feelings.  The child will know you can be approached because of the many times you approach them first on this topic (I know this is not your favorite discussion topic, so to get some practice give your mother-in-law a call and have a sexual conversation, or if you prefer then call a friend).

So armed with as much internal comfort as we can muster and ready to take the next step, where do we go from here?  I would suggest relying on some suggestions from Jan Hindman’s book There is No Sex Fairy To Protect Our Children From Becoming Sexual Abusers (Hindman, 2006) or what she calls the Ten Commandments of raising sexually respectful children:

  1. Start young to teach biology as well as respect.
  2. Communicate–Children are learning from many sources, they need to learn from you.
  3. Teach logic–rules, robbery, and rescue.  Everything in life has rules that need to be followed. Do not let someone take something precious from you against your will, and remember to always ask for help when you need it.
  4. Don’t keep children from the world–teach children healthy information and critical thinking.
  5. Teach gender equality and the meaning of consent.
  6. Sexual respect goes beyond biology and nature. Respect is not automatically learned.
  7. People don’t end up bad if bad things are done to them. Teach resiliency and personal responsibility.
  8. Teach delaying gratification and self-esteem.
  9. Teach RESPECT—the vulnerability of others, healthy guilt, restitution, the feelings of others, and anti-bullying.
  10. Teach touching and tenderness through your modeling at all ages.

As you are probably aware, sexual abuse can distort a child’s interest and curiosity.  Although not all interest in sex is a sign of pathology, in the same way not all interest in sex is normal and natural.  Therefore you as the parent must distinguish between healthy and unhealthy interests along with thoughts, feelings and sexual behavior.  Fortunately there are some resources in this area.  One is my own measure called the Inappropriate Sexual Behavior Scale, which can be found in my book Raising Children Who Refuse To Be Raised (Ziegler, 2000). Another resource is the booklet Understanding Children’s Sexual Behaviors (Cavanaugh Johnson, 2004). Both resources can help you distinguish from a wide range of healthy and unhealthy sexual themes in children.

Example of unhealthy themes that point to concern are the following: preoccupation with sex, sex play with much younger children, precocious knowledge beyond the child’s age, unusual sexual interests, drive to act out sexually, sex play that has a negative impact on other children, seeing others as sex objects, violating the rights and boundaries of others,  adult-like sexual activity, directing sexual behavior toward adults, sexual activity with animals, the use of sex to hurt others, bribery, threats, force to engage other children in sex play (Cavanaugh Johnson, 2004).

Now that your blood pressure was raised by the above list, some suggestions to handling sexual behavior may help calm you down.  The following are eight general principles for working with sexual behavior in all children:

  1. Remove the aura of sex and consider it as behavior, nothing more/nothing less.
  2. Work on being more comfortable talking about sexual issues.
  3. See the child and not just the behavior.
  4. Translate the meaning to the child of the sexual behavior, some sexual behavior is about attention not about sex.
  5. Consult with a partner, we often need a reality check when dealing with sexual behavior.
  6. Don’t minimize and don’t catastrophize.
  7. Don’t expect children not to be sexually curious at every age.
  8. Be sure to replace every problematic behavior with an alternative appropriate behavior.

Raising the sexually abused child can make your job even more difficult than the child who has not been abused. Sexual abuse often causes children to view sex as bad and yet they are attracted to it.  When adults view sexual themes as bad, this reinforces the problem. The answer to this dilemma is to transform sex into something positive.  Remember the goal is to promote healthy sexual interest, not stamp out all sexual interest.

Perhaps the most that can be done on this topic in a brief way is to provide a road map for the journey.  There will undoubtedly be some twists and turns along the way and a few surprises as well.  Here are some final practical suggestions to help guide you on this complex journey toward healthy sexuality for your child (and for you as well).

  • Go over rules of touching, space, and consent.
  • For young children use the language of playing games, “We don’t play the penis touching game in our home.”
  • Teach the child that our bodies are like our other important possessions, we care for them and protect them.
  • In teaching the child to be safe, he or she has already found the dangers, help the child learn how to determine the good from the bad.
  • Teach critical thinking, “In the story I just told you who was right and who was wrong?”
  • Talk to the child about the dangers in the world and how to avoid them, don’t pretend they are not there.
  • Explain to the child the people and places to avoid and why. Don’t teach fear, explain the hazards.
  • Your home must be an environment of respect in all areas.
  • Respect starts with people and objects then moves to sexuality.
  • You must specifically teach respecting boundaries to children who have had their private space violated.
  • Help children separate who they are from what was done to them.
  • Realize that many abused children have negative views of self and the future, you need to help them alter these views.
  • Teach children how to bounce back from adversity not only with sexual abuse but with all challenges in life.
  • Point out when the child overcomes difficult challenges and reinforce these small successes.
  • Responsibility must be specifically taught, it does not come naturally.
  • Sexuality is an extension of many aspects of life–respect, caring, intimacy, equality, and consideration.
  • Reframe the meaning of touch to include caring and loving touch.
  • Touch must be a communication of a positive message, not exploitation and abuse.

This has been a considerable amount of information in a few short pages and there is obviously a great deal more that could be said.  There is no quick and easy way to handle one of the most difficult aspects of the world’s most difficult job—parenting a healthy child, particularly when the child has been traumatized.  Becoming overly stressed will work against you, so do your best to relax and take it one step at a time.  The beauty of parenting is that there is little you can do wrong that can’t be fixed with time and effort.  There is no way to avoid the fact that parents must be the message they want their children to understand and internalize—teaching is fundamentally about modeling.  However, you are not expected to be an expert at either parenting the traumatized child or helping sexually abused children develop healthy sexuality.  In fact, there are no experts at this very challenging task, we are all early explorers of a complex and uncharted terrain.  Along the way make sure you take advantage of your personal support system and do not be reluctant to ask for help and some directions from time to time.  And good luck on your pioneering journey, both you and your child will gain from your efforts.

_______________________________

Advocates for Youth.  Sex Education for Physically, Emotionally, and Mentally Challenged Youthhttp://www.advocatesforyouth.org.

Cavanaugh Johnson, T.  (2004).  Understanding Children’s Sexual Behaviors.  What’s Natural and Healthy.  San Diego:  Family Violence and Sexual Assault Institute.

Hindman, J.  (2006).   There is No Sex Fairy To Protect Our Children from Becoming Sexual Abusers.  Lincoln City, OR: AlexAndria Associates.

Ziegler, D.L.  (2000).  Raising Children Who Refuse To Be Raised, Parenting skills and Therapy Interventions For The Most Difficult Children.  Phoenix: Acacia Publishing.

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.

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.

Appropriate and Effective Use of Psychiatric Residential Treatment Services

By Dave Ziegler, Ph.D. 

Executive Summary 

Stakeholders in a comprehensive system of care view psychiatric residential treatment as a dynamic and critical component interfacing with an effective overall mental health system for children (Butler & McPherson, 2006).  To be most effective PRTS must be targeted, responsive, and individualized to the needs of the child and the family and have the following characteristics: 

  • Integrated into the overall system of care and includes a continuum of step-up and step- down services within the same provider organization.
  • Offers a comprehensive and ecological model of multi-model treatment interventions into an integrated whole, designed to meet the individual needs of a child and the child’s family.
  • Commitment to national standards of excellence, a continuous commitment to quality improvement, and have an identifiable treatment philosophy and approach based upon research and empirical evidence.
  • Emphasizes the environment around the child that will necessitate family interventions, partnering with families during and after residential services to best meet the child’s needs.
  • Makes an impact on the child’s positive thoughts and perceptions, emotional self-regulation, and pro-social skills and behaviors.

Psychiatric residential treatment services can play several effective roles within the overall system including: a. intensive treatment while maintaining safety, b. a component of a step up/step down plan for a child, c. Treatment of serious disorders that require coordinated multimodal interventions, d. assessing medication level while providing a stabilizing environment, e. alternative to psychiatric hospitalization, and f. a treatment of last resort for children for whom other interventions have been ineffective. 

Less appropriate uses of PRTS include: a holding place for a child waiting for a community placement, destabilizing the child by rapidly altering medications or delving into deeper psychological states without sufficient time to re-stabilize, and when the length of time in PRTS is predetermined before admission due to cost, utilization, or other factors unrelated to the needs of the child. 

The commonly repeated criticisms concerning the lack of research support for the effectiveness of PRTS lack validity.  The comprehensive nature of a multimodal integrated environment presents unusual challenges for isolating variables for causal research.  However, considerable research exists to support the overall effectiveness and efficacy of PRTS. 

When efforts are made to insure that the proper children are admitted to well designed PRTS, the child, the family, and the system of care can expect individualized, client-centered care that can result in positive outcomes for everyone. 

Introduction–Efficacy and Effectiveness of PRTS 

A common goal among all stakeholders in the system of care for children is to develop a comprehensive array of services that is sensitive to the needs of children and their families and provides needed care on a continuum of intensity based upon individualized needs.  For over fifty years there has been a debate concerning putting children in out-of-home placements.  The debate has continued whether this it is the orphan asylum of the past or the psychiatric residential treatment center of the present.  For a variety of reasons, some well deserved, residential care has been plagued by negative stereotypes and pessimistic sentiments (Frensch & Cameron, 2002). A persistent notion that institutional life is contrary to a child’s nature (Whittaker, 2004) has led to “an archaic and inaccurate perception of residential treatment as a single type of ineffective, institutional congregate care for children” (Butler & McPherson, 2006). However, the long standing debate over residential settings has gradually given way to an acknowledgement that the best system of care includes alternatives for the needs of all children regardless of the level of required intensity (Leichtman, 2006; Butler & McPherson, 2006; Lieberman, 2004).  Therefore the question has changed from whether residential treatment should used, to what is the appropriate and effective use of residential treatment in the new system of care. 

There is considerable literature and research support for the value of residential treatment of a broad variety of types and approaches, particularly for the sophisticated treatment settings that have met the highest national standards of excellence (CWLA, 2004; Lewis, 2004; Friman, 2000; Handweck, Field & Friman, 2001; Larzelere, Daly, Davis, Chmelka & Handwerk, 2004; Lipsey & Wilson, 1998; Lyman & Wilson, 1992; Pfeifer & Strelecki, 1990; U.S. Department of Health and Human Services, 1999). “Residential services are an important and integral component within the multiple systems of care and the continuum of services” (CWLA, 2005). This statement from the largest children’s advocacy organization in the country outlines the new thinking coming from policy makers, system managers, advocates, families, and providers.  The many arguments against the use of residential care of the past, including the comparison of one level of care over another, are out of favor due to improper comparisons and lumping divergent services (Handwerk, 2002; Butler & McPherson, 2006). In its place is a more inclusive and practically position that there will always be a number of youth who require the intensive structure and safety of the residential setting. Whether it is the Child Welfare League of America, the Building Bridges initiative, or the providers themselves (AACRC and others), there is wide support from stakeholders that residential care is an essential and important part of the overall system of care past, present and into the future. 

The psychiatric residential treatment program of today is not the same as programs of the past, including the very recent past.  This fact makes most comparisons to current care and the residential treatment of the past questionable in their validity.  The quality Psychiatric Residential Treatment program of today is not only integrated into the overall system of care, but includes a continuum of step-up and step-down services within the same provider organization.  Such an internal system of care allows for children and families to change levels of treatment intensity without changing key staff such as psychiatrists, therapists, teachers, and mentors.  For child with significant mental health needs, the level of treatment intensity will necessarily change over time if the plan of care is effective. 

What Constitutes Good Psychiatric Residential Treatment Services 

A quality residential program offers a comprehensive and ecological model (Stroul & Friedman, 1996; Wells, Wyatt & Hobfoll, 1991; Hooper, Murphy, Devaney & Hultman, 2000) of multi-model treatment interventions woven into an integrated whole, designed to meet the individual needs of a child and the child’s family.  The best programs start with a commitment to national standards of excellence, a continuous commitment to quality improvement, and have an identifiable treatment philosophy and approach based upon research and empirical evidence.  Effective programs will emphasize the environment around the child that will necessitate family interventions, partnering with families to best meet the child’s needs, and at times may include efforts to identify a family for children without one.  Good residential programs know the target populations that they are most effective with and have evidence based approaches for these populations.  Good programs make positively impacts on the child’s positive thoughts and perceptions, emotional self-regulation, and pro-social skills and behaviors.  The best residential programs are integrated into a community of stakeholders who have input into a continual unfolding of quality interventions in an overall environment of safety, respect and effectiveness. 

The Best Use of Residential Treatment 

For too long residential treatment has been relegated primarily to the placement of last resort.  In some situations it may be the case that a child has been unresponsive to treatment that is less intense or insufficiently environmentally integrated, thus necessitating the strengths of a residential setting.  The use of residential care as a “last resort” is still a possible role but there can be other roles as well: 

Intensive treatment while maintaining safety—Some children cannot be effectively and safely treated in a family setting.  Examples of this are serious violent behavior, firesetting, and significant sexual behavior. 

One component of an overall treatment continuum—At times the needs of a child may warrant treatment in a variety of settings from maximal to minimal levels of intensity as treatment progresses.  Residential care can be an important part of the plan including a back up to serious deterioration in levels of care in community settings. 

Treatment of serious disorders that require multimodal intervention—Children with the highest acuity of psychiatric needs often require a complex array of integrated services in a single setting.  An example of this are complex trauma disorders where up to a dozen specialized intervention strategies may be needed (Connor, Miller, Cunningham & Melloni, 2002). 

Safely assessing psychopharmacological intervention—A child may have serious emotional or behavioral destabilization when medications are significantly altered.  For children with several medications, it may be important to insure safety for the child and all concerned while the medication assessment process takes place. 

Alternative to hospitalization—A well designed psychiatric residential program can be an effective alternative to hospitalization for many serious children.  This can provide advantages including: keeping the child and family in the community, intensive care in a less restrictive setting, and a significant reduction in cost allowing a length of stay appropriate for the child. 

There are also ways that residential treatment should not be used.  It should not be a default setting for a child who has completed treatment but is waiting for a placement.  A residential setting should not be allowed to destabilize a child’s mental health, such as changing medications or opening painful psychological issues without sufficient time to follow through with the ramifications.  While there are children who have been shown in research to improve with short stays of six months or less in residential care (Blackman, Eustace, Chowdhury, 1991; Leichtman, Leichtman, Barker & Neese, 2001; Shapiro, Welker & Pierce, 1999), this is based upon a short-term approach of lowering the expectations of treatment through modest and selective goals such as primarily addressing the issue that caused the removal of he child from the family home (Leichtman & Leichtman, 1996).  However there is still a place for longer term treatment with specific childhood disorders that are not responsive to short-term interventions (Zegers, Schuengel, van IJzendoorn & Jansserns, 2006; McNeal, Handwerk, Field, Roberts, Soper, Huefner & Ringle, 2006; Greenbaum, Dedrick, Friedman, Kutash, Brown, Lardieri & Pugh, 1996).  Residential treatment is improperly used when the length of intensive residential treatment is predetermined before admission due to cost, utilization or other factor unrelated to the needs of the child. 

Efficacy and Effectiveness of Residential Treatment 

It is commonly stated that residential treatment has been shown not to be effective.  A closer look at efficacy and effectiveness tells a different story. While there have been weaknesses among the providers of residential care over the years, there have also been very effective services delivered in a residential setting.  This point raises an important distinction between an intervention and a setting.  Too often this distinction is misunderstood resulting in ‘apples and oranges’ comparisons (Butler & McPherson, 2006).  For example, an evidenced based intervention can be effective in a variety of settings, or the wrong evidence based intervention in a specific setting can be highly ineffective.  When discussing whether a placement is the best choice, both the setting and the interventions to be used are both important considerations. 

Science is informing the mental health world at an unprecedented pace.  Objective research is increasingly being considered to inform decision makers, parents and providers as to what to do more of, and what to discontinue.  Science considers all aspects of a situation to form an opinion, not just factors that confirm previous biases. Because there has been a fifty year debate over putting children in residential setting, both sides have presented data to enhance their argument, for or against. We must now move beyond previous biases and look toward objective science. 

Whether a treatment setting works depends upon both efficacy and effectiveness.  Objectively speaking there is research to support strong efficacy in residential care.  At the same time there are consistent questions as to the effectiveness reflected in research on residential treatment (Hair, 2005).  This apparent contradiction points to the difficulty in evaluating whether a complex setting works or not.  The answer often depends upon the way the question is framed, as well as how outcomes are measured.   

There has been decades of research evidence of efficacious treatment of children and adolescents in all settings.  When children who receive a broad variety of treatments are compared with control groups of children receiving no treatment, the treatment group is consistently superior with an effective size from .7 to .8 (Casey & Berman, 1985; Baer & Nietzel, 1991; Burns, Hoagwood & Mrazek, 1999; Grossman & Hughes, 1992; Hazelrigg, Cooper & Borduin, 1987; Kazdin, Siegel & Bass, 1990; Shadish, Montgomery, Wilson, Wilson, Bright & Okwumabua, 1993; Weisz, 1987; Weisz, Weisz, Han, Granger & Morton, 1995).  Some treatments and some settings have shown better results than others, but treatment efficacy research provides strong and consistent evidence that providing psychological treatment to child clients is much better than not doing so. 

Much has been made of the scarcity of causal research on residential treatment.  The reason that effectiveness research on residential settings has been either mixed or lacking is primarily due to the complex weave of multiple treatments in an ecological setting.  Such an enriched setting of multi-modal treatment variables is not conducive to empirical causal research.  Moreover, “the very characteristics that are likely to make (treatment) effective make them more difficult to describe and evaluate…numerous elements of family and agency life weave together with the therapeutic intervention and potentially decrease the chance of finding a positive treatment effect when there is one” (Hair, 2005). Butler and McPherson point out that this lack of empirical evidence in part is based upon the challenge of measuring what residential care does best.  They report gains such as:  enhanced safety, truancy reductions, consistent medication management, reduced hospitalizations, consistency, structure, caring and nurturing, limit setting, psychosocial support, self-esteem role modeling, time to self-reflect, and focus on mental health issues, all of which are invaluable to the child but are complicated to objectify and analyze. “Thus the literature does not actually reveal much helpful information” (Butler & McPherson, 2006). 

Some of the research showing marginal or no positive efficacy makes the conceptual error of comparing some new type of treatment intervention with the traditional treatment setting of residential care.  There are studies that indicate poor outcomes with residential care (Burns et.al., 1999; Greenbaum et.al., 1996; Friman, 2000; Ruhle, 2005).  Some of these studies again address a setting, not specific treatment interventions.  Research on essentially all settings can find poor outcomes (families, hospitals, foster care, schools, etc.). For example, while there is considerable evidence of effectiveness for some uses of family based treatment foster care, other uses have been found to be contraindicated (Farmer, Wagner, Burns & Richards, 2003), or less effective for some populations than residential care (Drais-Parrillo, 2005). Treatment settings in themselves do not insure effectiveness, this can only be done by quality interventions within a treatment setting.              

When treatment interventions are the subject of research residential settings the results often show strong improvement (Landsman, Groza, Tyler & Malone, 2001; Hooper et. al., 2000; Weiner & Kupermintz, 2001; Burns et.al., 1999).  Research has shown long-term maintenance of gains in clinical functioning, academic skills and peer relationships (Blackman, Eustace & Chowdhury, 1991; Joshi & Rosenberg, 1997; Wells, 1991). 

Two predictors of long-term positive outcomes deserve to be specifically mentioned.  The quality of the therapeutic relationship in therapy has been found to be one of the most important predictors of long-term success (Pfeifer & Strzelecki, 1990; Scholte & Van der Ploeg, 2000).  In a recent study on attachment representations, children in residential treatment improved in their forming secure attachments and decreasing their avoidance and hostile behavior.  However this finding was true only for children with longer stays in residential treatment.  The study reported, “When the duration of treatment is extended, the personal attachment backgrounds of clients and treatment staff increase in importance (Zegers, Schuengel, van IJzendoorn & Jansserns, 2006).  The other long-term predictor of success is positive outlook, life satisfaction and hopefulness.  In a 2006 study children in residential treatment increased their hopeful thinking and general well-being, while decreasing psychopathology (McNeal, Handwerk, Field, Roberts, Soper, Huefner & Ringle, 2006). Attitudinal and cognitive variables such as hope have been found to predict outcomes above and beyond psychopathology (Hagen, Myers & MacKintosh, 2005). This study on hope found the children with the highest levels of psychopathology made the most gains after 6 months of residential care. 

Therefore a quick statement on the general findings of research indicate: strong support for providing treatment services to child over no treatment, mixed results when evaluating the setting, and strong support for effectiveness with specific treatments in residential settings.  It can therefore be said that, in general, treatment provided to the child will be better than none at all, and it is the treatment interventions used in the residential setting that are the determining factor of efficacy and not the setting itself. 

The Right Target Population for Psychiatric Residential Treatment 

Intensive treatment services in a residential setting are restrictive and potent and should only be a part of the plan of care for a child if needed.  There is common agreement that care should be taken before placing a child out of a family setting and particularly when placing the child in a PRTS program.  It is important that guidelines exist concerning the right target population while not being so prescriptive that children ‘fall through the cracks.’  To avoid legislating children out of a needed service, it is essential that the individual child’s needs must come first, and the child matched to the proper level of care intensity.  The overall criteria for such a restrictive setting is to include only those children who cannot receive the treatment they need while remaining in a family setting.   The historical criteria for admission to PRTS have been: 

  1.  Other treatment resources available in the community do not meet the treatment needs of the child.
  2. Proper treatment of the child’s psychiatric condition requires services in a psychiatric residential treatment setting under the direction of the psychiatrist.
  3. The services can be reasonably expected to improve the child’s condition or prevent further regression so that psychiatric residential services may no longer be needed
  4. The child has a principal diagnosis of Axis I of a completed 5-Axis DSM diagnosis that is not solely a result of mental retardation or other developmental disabilities, epilepsy, drug abuse, or alcoholism. 

These criteria have provided guidelines while allowing for individual needs to be considered.  If proper treatment resources exist in the community, if the child does not need psychiatric oversight, if the treatment can help or prevent further deterioration and if they child has a mental health diagnosis, then the child can be considered.  As the system focuses on improving community resources, more children would be screened out due to the first criteria. 

The one screening tool that has been used in the past is the Childhood Acuity of Psychiatric Illness.  It has been used to inform the admission and discharge decisions but has not been the sole criteria.  Like the CASII, where it is possible to have an overall low acuity score yet be appropriate for intensive treatment due to high risk behavior, the CAPI scores do not address all areas of need or interest when making admission decisions.  Therefore it cannot be used solely as an indication of proper or improper placement decisions. 

There is general agreement that treatment should be individualized, strength-based, and integrated.  Therefore it is important to insure that admission and discharge decisions are individualized and not based upon a score or single or multiple indicators not related to the needs of the child. 

It is important that the child have a serious mental health issue to be appropriate for PRTS.  However, the treatment needs of the child should be the primary consideration and not the diagnostic category, which often varies by practitioner.  Frequently a child’s diagnosis changes when the provider changes.  Diagnostic categories are not discreet in many cases and children needing PRTS care typically have multiple Axis I diagnoses. The diagnosis of a child at admission has been found to be a negligible factor in success at discharge (Hair, 2005), thus the specific diagnosis should not be used as a factor to screen a child in or out of PRTS. For example, lf a child is dangerous due to a mental health diagnosis, the child should not be screened out due to which diagnosis the child has been given.  Using another example, if a child is suicidal and has a serious oppositional defiant diagnosis, the child should receive the treatment needed in a safe setting, which could necessitate a PRTS level of care, regardless of the diagnosis. 

Research consistently indicates that children with supportive families do better in general, do better in school, do better in treatment, and do better coming out of PRTS.  This makes logical sense.  However, true trauma informed care necessitates that a child who is unlucky enough to receive poor family support or who has lost his or her biological family, should not be further neglected by the system and prevented from receiving PRTS care if that is the indicated need.  Developing an aftercare resource becomes an important part of the plan of care.  Trauma informed care also requires that the treatment reflects the child’s past, provides effective trauma treatment, and insures safety, predictability, and stability of placement while intensive trauma treatment is provided.  For a seriously traumatized child, focusing solely on stabilizing a child’s behavior without providing intensive trauma treatment is not individualized, nor is it responsive to the needs of the child and family. 

Summary 

Psychiatric residential treatment is an important and essential component of the mental health system of care.  The best treatment programs are ecological in orientation and combine all the needed components to best help the child and family.  Despite the fact that ecological treatment settings are not conducive to quantitative causal research designs, they have been shown to be some of the most effective services for children with multiple needs.  Psychological treatment has shown decades of strong support across settings and has been shown effective when interventions in residential settings are considered rather than the setting itself.  The family must be involved in both decision making and intensive treatment along with the child.  If a child has lost his or her family for whatever reason, the child should not be further neglected by not receiving the level of intensive treatment services needed.  The right target population should be afforded PRTS.  Adhering to the historical criteria has shown that the right children receive the right level of care.  Reliance on any one score, instrument or factor alone is contraindicated for PRTS as it is for any placement decision for a child.  The admission decision on a child must be individualized with the needs of the family taken into consideration.  The treatment must conform to the child and family and not expect the child to conform to the treatment.  This includes both treatment programs as well as the overall system of care.  When a PRTS program is carefully designed with multi-modal treatments to address the complex needs of the child, and individualized in partnership with the family, this intervention can turn the most seriously challenging children in the system of care into some of the most improved consumers.  Such an outcome is one that is desirable to all stakeholders in the system of care.  

References 

Baer, R.A. & Nietzel, M.T.  (1991).  Cognitive and behavioral treatment of impulsivity in children:  a meta-analytic review of the outcome literature.  Journal of Clinical Child Psychology, 20, 400-412.  

Burns, B.J., Hoagwood, K. & Mrazek, P.J.  (1999).  Effective treatment for mental disorders in children and adolescents.  Clinical Child and Family Review, 2, 199-254. 

Butler, L.S. & McPherson, P.M.  (2006).  Is Residential Treatment Misunderstood?  Journal of Child and Family Studies. 

Blackman, M., Eustace, J. & Chowdhury, T.  (1991).  Adolescent residential treatment:  A one to three year follow-up.  Canadian Journal of Psychiatry, 36, 472-479. 

Casey, R.J. & Berman, J.S. (1985). The outcome of psychotherapy with children.  Psychological Bulletin, 98, 388-400.  

Connor, D.F., Miller, .P., Cunningham, J.A. & Melloni, R.H. (2002).  What does getting better mean?  Child improvement and measure of outcome in residential treatment.  American Journal of Orthopsychiatry, 72, 110-117. 

Child Welfare League of America.  (2004).  Standards of excellence for residential services (revised).  Washington, DC. 

Child Welfare League of America.  (2005).  Position Statement on Residential Services.  Washington, D.C. 

Drais-Parrillo, A.A.  (2005).  The Odyssey Project:  a descriptive and prospective study of children and youth in residential group care and therapeutic foster care.  Child Welfare League of America, Washington D.C. 

Farmer, E.M., Wagner, H.R., Burns, B. J. & Richards, J.T.  (2003) Treatment foster care in a system of care: Sequences and correlates of residential placement. Journal of Child and Family Studies, 12, 11-25. 

Frensch K.M. & Cameron, G.  (2002).  Treatment of choice or a last resort? A review of residential mental health placements for children and youth.  Child and Youth Care Forum, 31, 307-339. 

Friman, P.C.  (2000).  Behavioral, family-style residential care for troubled out-of-home adolescents:  Recent findings.  In J. Austin & J.E. Carr (Eds.), Handbook of applied behavior analysis.  Reno NV: Context Press. 

Greenbaum, P.E., Dedrick, R.F., Friedman, R.M., Kutash, K., Brown, E.C., Lardieri, S.P. & Pugh, A.M.  (1996).  National adolescent and child treatment study (NACTS):  Outcomes for children with serious emotional and behavioral disturbance.  Journal of Emotional and Behavioral Disorders, 4, 130-146. 

Grossman, P.B. & Hughes, J.N.  (1992).  Self-control interventions with internalizing disorders:  A review and analyses.  School Psychology Review, 21, 229-245. 

Hair, H.J.  2005.  Outcomes for Children and Adolescents After Residential Treatment:  A Review of Research from 1993 to 2003.  Journal of Child and Family Studies (14), 4, 551-575.219. 

Hagen, K.A., Myers, B.J. & MacKintosh, V.H.  (2005).  Hope, social support, and behavioral problems in at-risk children.  American Journal of Orthopsychiatry, 75, 211-219. 

Handweck, M.L., Field, C. & Friman, P.C. (2001).  The iatrogenic effects of group intervention for anti-social youth:  Premature extrapolations?  Journal of Behavioral Education, 10, 223-238. 

Handwerk, M.L. (2002).  Least restrictive alternative: Challenging assumptions and further implications.  Children’s Services: Social Policy, Research & Practice, 5, 99-103. 

Hazelrigg, M.D., Cooper, H.M. & Borduin, C.M.  (1987).  Evaluating the effectiveness of family therapies: an integrative review and analysis.  Psychological Bulletin, 101, 428-442.  

Hooper, S. R., Murphy, J., Devaney, A. & Hultman, T.  (2000). Ecological outcomes of adolescents in psychoeducational residential treatment facility.  American Journal of Orthopsychiatry, 70, 491-500. 

Joshi, P.K. & Rosenberg, L.A.  (1997).  Children’s behavioral response to residential treatment.  Journal of Clinical Psychology, 53, 567-573. 

Kazdin, A.E., Siegel, T.C. & Bass, D.  (1990).  Drawing on clinical practice to inform research on child and adolescent psycholtherapy: Survey to practitioners.  Professional Psychology: Research and Practice, 21, 189-198. 

Landsman, M.J., Groza, V., Tyler, M. & Malone, K.  (2001). Outcomes of family-centered residential treatment.  Child Welfare, 80, 351-379. 

Larzelere, R.E., Daly, D.L., Davis, J.L., Chmelka, M.B. & Handwerk, M.L.  (2004).  Outcome evaluation of the Birls and Boys Town Family Home Program.  Education & Treatment of Children, 27, 131-148. 

Leiberman, R.E. (2004). Future directions in residential treatment.  Child and Adolescent Psychiatric Clinics of North America, 13, 279-294. 

Leichtman, M.  (2006).  Residential treatment of children and adolescents:  Past, present and future.  American Journal of Orthopsychiatry, 76, 285-294. 

Leichtman, M. & Leichtman, M.L.  (1996).  A model of short-term residential treatment: General Principles and Changing Roles.  In W. Castro (Ed.), Contributions to residential treatment, 1996.  Alexandria, VA:  American Association of Children’s Residential Centers. 

Leichtman, M., Leichtman, M.L., Barker, C.B. & Neese, D.T.  (2001).  Effectiveness of intensive short-term residential treatment with severely disturbed adolescents.  American Journal of Orthopsychiatry, 71, 227-235. 

Lipsey, M.W. & Wilson, D. (1998).  Effective intervention for serious juvenile offenders:  A synthesis of research.  In R. Loeber & D.P. Farrington (Eds.), Serious & violent juvenile offenders: Risk factors and successful interventions.  Thousand Oaks, CA: Sage Publishing. 

Lewis, M.  (2004).  Residential treatment: Forward.  Child and Adolescent Psychiatric Clinics of North America, 13. 

Lyman, R.D. & Wilson, D.R.  (1992).  Residential and inpatient treatment of emotionally disturbed children and adolescents.  In C.E. Walker & M.C. Roberts (Eds.), Handbook for clinical child psychology (2nd ed.),  Oxford, UK: Wiley Publishing. 

McNeal, R., Handwerk, M.L., Field, C.E., Roberts, M.C. Soper, S., Huefner, J.C. & Ringle, J.L. (2006).  Hope as an outcome variable among youth in a residential care setting.  American Journal of Orthopsychiatry, 76, 304-311. 

Pfeifer, S.I. & Strelecki, S.C. (1990).  Impatient psychiatric treatment of children and adolescents:  A review of outcome studies.  Journal of the American Academy of Child & Adolescent Psychiatry, 29, 847-853. 

Ruhle, D.M.  (2005).  Take care to do no harm:  Harmful interventions for youth problem behavior.  Professional Psychology: Research and Practice, 36(6), 618-625. 

Scholte, E.M. & Van der Ploeg, J.D.  (2000).  Exploring factors governing successful residential treatment of youngsters with serious behavioral difficulties:  Findings from a longitudinal study in Holland.  Childhood: A Global Journal of Child Research, 7, 129-153. 

Shadish, W.R., Montgomery, L.M., Wilson, P., Wilson, M.R., Bright, I & Okwumabua, T.  (1993). Effects of family and marital psychotherapies: A meta-analysis.  Journal of Consulting and Clinical Psychology, 61, 992-1002.  

Shapiro, J.P., Welker, C.J. & Pierce, J.L. (1999).  An evaluation of residential treatment for youth with mental health and delinquency-related problems.  Residential treatment for Children and Youth, 17, 33-48. 

Stroul, B.A. & Friedman, R.M.  (1996).  The system of care concept and philosophy.  In B.A. Stroul (Ed.), Children’s mental health:  Creating systems of care in a changing society.  Baltimore:  Paul H. Brookes. 

U.S. Department of Health and Human Services, (1999).  Mental health:  A report of the Surgeon General.  Rockville, MD. 

Weiner, A. & Kupermintz, H.  (2001).  Facing adulthood alone:  The long-term impact of family break-up and infant institutions:  A longitudinal study.  British Journal of Social Work, 31, 213-234. 

Weisz, J.R.  (1987).  Effectiveness of psychotherapy with children and adolescents: A meta-analysis for clinicians.  Journal of Consulting and Clinical Psychology, 55(4), 542-549. 

Weisz, J.R., Weiss, B., Han, S.S., Granger, D.A. & Morton, T.  (1995).  Effects of psychotherapy with children and adolescents revisited:  A meta-analysis of treatment outcome studies.  Psychological Bulletin, 117, 450-468. 

Wells, K. (1991).  Placement of emotionally disturbed children in residential treatment:  A review of placement criteria.  American Journal of Orthopsychiatry, 61, 339-347. 

Wells, K., Wyatt, E. & Hobfoll, S.  (1991).  Factors associated with adaptation of youths discharged from residential treatment.  Children and youth Services Review, 13. 

Whitaker, J.D.  (2004). The re-invention of residential treatment:  An agenda for research and practice.  Child and Adolescent Psychiatric Clinics of North America, 13, 267-278. 

Zegers, A.M., Schuengel, C., van IJzendoorn, M.H. & Jansserns, J.M.  (2006).  Attachment representations of institutionalized adolescents and their professional caregivers:  Predicting the development of therapeutic relationships.  American Journal of Orthopsychiatry, 76, 325-334.