Treating the Whole Child, Not Just Symptoms

By Dave Ziegler, Ph.D.

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

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

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

Physical

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

Mental/Neurological

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

Spiritual/Attitudinal

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

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

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

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

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

 

Treating the Whole Child: Mind, Body & Spirit

 

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

Some descriptions and interventions can be helpful.

Physical

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

Mental/Neurological

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

Spiritual/Attitudinal

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

Interventions

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

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

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

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

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

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

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

Summary

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

Where to get more information on treating the whole child

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

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

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

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

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

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

By Dave Ziegler, Ph.D.

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

Neurological Reparative Therapy: The Treatment Model of Jasper Mountain

By Dave Ziegler, Ph.D.

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

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

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

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

The Ten Fundamental Premises of NRT

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

Five Goals

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

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

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

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

2.   Enhance neuro-integration

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

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

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

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

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

4.   Facilitate Orbitofrontal Cortex activation

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

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

5.   Neuro-template development through repetitive practice

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

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

Five Steps

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

1.   Assess the extent and causes of neurological impairment

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

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

2.   Identify specific cognitive, emotional and behavioral problematic symptoms

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

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

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

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

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

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

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

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

5.   Environmental enhancements promoting the building blocks of brain development

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

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

Conclusion

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

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

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

By Dave Ziegler, Ph.D. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References 

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

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

American Psychiatric Association, Arlington, VA. 

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

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

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

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

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

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

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

Lamberti, J.S. & Cummings, S.  (1992).  Hands-on restraint in the treatment of multiple personality disorder.  Hospital and Community Psychiatry, 43 (3), 283-284. 

Measham, T.J. (1995).  The acute management of aggressive behaviors in hospitalized children and adolescents.  Canadian Journal of Psychiatry, 40 (6), 330-336. 

Miller D., Walker, M.C. & Friedman D.  (1989). Use of a holding technique to control the violent behavior of seriously disturbed adolescents.  Hospital and Community Psychiatry, 40 (5), 520-524. 

National Association of Psychiatric Health Systems, Washington, D.C. 

National Technical Assistance Center for State Mental Health Planning (2002).  Networks , Alexandria, VA. 

Rolider, A., Williams, L., Cummings, A. & Van Houten, R.  (1991).  The use of a brief movement restriction procedure to eliminate severe inappropriate behavior.  Journal of Behavioral Therapy and Experimental Psychiatry, 22 (1), 23-30. 

Smith, P.A.  (1993). Training Manual for Professional Assault Response Training Revised. 

Stirling, C. & McHugh, A.  (1998).  Developing a non-aversive intervention strategy in the management of aggression and violence for people with learning disabilities using natural therapeutic holding.  Journal of Advanced Nursing, 27 (3), 503-509. 

Sourander, A., Aurela, A. & Piha, J.  (1996).  Therapeutic holding in child and adolescent psychiatric inpatient treatment.  Nordic Journal of Psychiatry, 50 (5), 375-380. 

Sugar, M. (1994).  Wrist-holding for the out of control child.  Child Psychiatry and Human Development, 24(3), 145-155. 

Troutman, B., Myers, K., Borchardt, C., Kowalski, R. & Burbrick, J.  (1998).  Case study:  When restraints are the least restrictive alternative for managing aggression.  Journal of the American Academy of Child and Adolescent Psychiatry, 37 (5), 554-555. 

Wong, S.E. (1990).  How therapeutic is therapeutic holding?  Journal of Psychiatric Nursing & Mental Health, 28 (11), 24-28. 

Ziegler, D.  (2001).  To Hold, or Not to Hold…Is That the Right Question?  Residential Treatment for Children & Youth, 18 (4), 33-45. 

Ziegler, D. (2002).  Traumatic Experience and the Brain, A handbook for understanding and treating those traumatized as children.  Phoenix:  Acacia Press. 

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.  

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