Treating the Whole Child, Not Just Symptoms

By Dave Ziegler, Ph.D.

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

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

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

Physical

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

Mental/Neurological

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

Spiritual/Attitudinal

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

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

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

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

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

 

Treating the Whole Child: Mind, Body & Spirit

 

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

Some descriptions and interventions can be helpful.

Physical

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

Mental/Neurological

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

Spiritual/Attitudinal

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

Interventions

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

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

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

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

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

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

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

Summary

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

Where to get more information on treating the whole child

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

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

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

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

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

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

By Dave Ziegler, Ph.D.

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

Neurological Reparative Therapy: The Treatment Model of Jasper Mountain

By Dave Ziegler, Ph.D.

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

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

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

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

The Ten Fundamental Premises of NRT

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

Five Goals

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

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

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

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

2.   Enhance neuro-integration

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

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

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

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

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

4.   Facilitate Orbitofrontal Cortex activation

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

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

5.   Neuro-template development through repetitive practice

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

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

Five Steps

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

1.   Assess the extent and causes of neurological impairment

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

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

2.   Identify specific cognitive, emotional and behavioral problematic symptoms

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

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

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

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

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

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

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

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

5.   Environmental enhancements promoting the building blocks of brain development

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

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

Conclusion

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

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

A Residential Care Attachment Model

By Dave Ziegler, Ph.D.

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

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

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

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

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

How Jasper Mountain Started

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

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

How the Program Works

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

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

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

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

 What Makes the Difference?

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

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

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

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

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

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

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

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

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

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

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

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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