Maybe It’s Not the Consequences

Think about a child in your program who has significantly improved. Maybe it would be that boy who recently came back for a visit after a successful discharge. Or maybe it’s the girl who has finally stopped hurting herself and running away and who is excelling in African drumming.

What do you think made the difference for this child? What actually helped him or her change and heal?

Most likely you think of the relationships, the patience, the caring. It’s the fact that your team was able to stick with him through the hard times. Maybe you were able to make some progress in connecting her with her family. You noticed that after a while she started to feel safe in the program and began to relax and play more. Probably you taught her some skills- now she asks for her crisis kit when she gets upset, and uses her distress tolerance skills. Maybe he experienced some success- it was when he started doing well on the basketball team that he began his turn around, or when he had that work study job in the kitchen and connected with the cook and started to enjoy cooking. When he finally trusted his therapist enough to tell her that he hated feeling like an idiot when it came to math, that helped too.

In short, we all know that what changes children is the web of loving, patient relationships combined with many repetitive specific skill building activities.

Yet, when we are anxious and upset about a certain child or a certain behavior, our thoughts automatically turn first to consequences.

Janessa keeps running away. Maybe we should give her a longer restriction when she comes back.

Sam continues to be mean to the other boys. Maybe we should give him a reward for every day he is not mean.

How would our programs be if we operated from the assumption that the actions we take after a behavior occurs have NO EFFECT on that behavior? That when we are concerned about a behavior, all our creativity and effort should go into creating the safety and teaching the skills that will enable a child not to need that behavior any more?

Of course this is an exaggeration, our response to a behavior does have some effect on it. But it is actually not our most powerful point of intervention.

What then would we do when a behavior occurred?

What if we thought of that moment as a time to teach a kid what you do when you screw up. This is something we all need to know (I use my skills in this area regularly). This is also something our kids do not know. When they screw up they plunge into an abyss of hopelessness, think all is lost, and prepare to be kicked out.

So we have an opportunity to teach how to repair a mistake. How do we repair our own mistakes with our friends? Apologize, explain what happened, listen to the other person’s experience and take in how they felt, do something nice for them, and make an effort not to make the same mistake again.

Of course our kids can’t do all this. Shame and self hatred make it difficult. But we can lead them to do small steps, small parts and thus gradually and slowly increase their ability to right their wrongs.

And at the same time, we continue the day to day work of helping them develop the self capacities that will diminish the number of mistakes they need to make.

What do you think of this idea? Click on comment and share your response.

Foster Care Behavioral Guidelines

Healing Parents: Helping Wounded Children Learn to Trust & Love by Michael Orlans, Terry M. Levy
CWLA Press (Child Welfare League of America) (December 30, 2006)

Creating Capacity for Attachment: Dyadic Developmental Psychotherapy in the Treatment of Trauma-Attachment Disorders by Deborah Shell; Art Becker-Weidman Wood N Barnes (July 20, 2005)

I have improved my foster care guidelines, partly through consultation with these two books.

Again, this is only meaningful when imbedded in a context of training, supervision and support. I am currently working on developing a series of six training modules to deliver to our foster care program through out the up coming year.

All comments and suggestions would be most welcome.

Guidelines for Trauma-Informed Behavior Management in Foster Care

1. This approach to behavior management is based on the understanding that problem behaviors are the child’s attempt to manage intolerable emotions such as fear, despair and hopelessness. Because the child does not trust relationships and thus has trouble asking for and accepting help; because he or she has an overly activated nervous system; and because he or she has not learned emotion management skills, the child reacts to set backs with behaviors that help in the moment but have long term negative consequences.

2. The most powerful way to change behavior will be through forming strong relationships, creating attuned communication, creating a sense of self worth, and modeling and teaching emotion management skills.

3. Interactions with the children should be consistent with the Restorative Approach. They should display the qualities of playfulness, love, acceptance, curiosity, and empathy.

4. Whenever possible parents should promote attunement with their children. When there is a break in attunement, the parent should address it and reconnect.

5. Parents must understand that they need to help the child regulate his emotions, by remaining calm them selves, using soothing words, and naming and validating feelings.

6. Many children are shame based and do not feel worthy of life. Parents should be aware of the pervasiveness of shame, be careful not to shame the child, and understand the paralyzing effect of shame.

7. As the child begins to feel safe, her need for problem behaviors will decrease.

8. Building the relationship is more important than changing the behavior. In fact it is necessary before the behavior can change. Prioritize alliance, not compliance.

9. Behavioral difficulty should be handled through re-direction and persuasion. Consequences should not be threatened or imposed except as a last resort. Children can be kept closer in (i.e. kept to house, in sight of parents) when they have acted out, but should constantly be re-evaluated as to whether this is still necessary.

10. Points Levels and behavior charts are not used.

11. As soon as the child is back on track after any incident, they should resume normal activities.

12. Children who are having difficulty should be kept closer to parents. They should not go on trips or off on their own.

13. When a child is agitated, escalated or out of control, all parent efforts should be directed towards helping them calm down. This can be done through listening, validating, taking a walk, quiet, adult closeness and calmness. There should be no discussion at this time of consequences or better ways to handle things. These can be discussed later when the child is calm.

14. If a child has a major problem, they should be given a restorative task consistent with the problem they had. The task should include the elements of learning, making amends and reconnecting. In other words, they should be given opportunities to repair damage done, make amends to people hurt, restore damaged relationships, and do something nice for the family.

15. Until the child has completed their restorative tasks, they should not participate in extra or just-for-fun activities. They should be part of all regular activities. This means all regular therapy and school unless parents determine it’s unsafe for the child to be in these activities. They could go to bed earlier to get energy for their restorative work.

16. When the child has completed their restorative task, they should return to all normal activity.

17. Isolation to any room should not be used. Children become regulated in the presence of regulated adults.

18. Restrictions can be used (car, pool, etc). These are used when a child is not safe while doing these activities. They should be for short times such as a day or two and constantly reevaluated.

19. Children can be asked to leave the family area (if possible, with an adult) to calm down or re focus, and then return in a short time (5-15 minutes), but this should be done only rarely- children are most likely to calm down when close to calm adults, not when sent off by themselves.

20. Structure is extremely important and the children need a highly structured day with planned activities, and they are helped by knowing what will happen next. Families maintain order throughout the day by such mechanisms as plans, describing what will happen next, taking turns, quiet time, and game playing. Alternating quiet activities with more energetic activities helps the kids contain their emotions. When kids are unsafe, keeping them to a small circle of activities and people is helpful; taking them to events like large family picnics may be a set up for difficult behavior. Choices should be limited. Free time, alone time, and going to bed are particularly difficult and should be supported by the adult. Events in which there is a lot of noise, confusion and stimulation (such as shopping) can also be difficult for some children. The adults should try to structure the child’s day so he experiences success, not put him in situations for which he is not prepared. Routines, rituals and ceremonies are very helpful in establishing a safe structure in the home.

21. Bedtime and hygiene are particularly sensitive times for children who have experienced trauma. Problems in these areas should not be addressed through punishments or rewards. The children should be supported through parent closeness and creative interventions such as music, night lights, bubble baths, etc.

22. When a child’s behavior begins to deteriorate, the first question to ask is: is she feeling safe? The second question is: is she over stimulated?

Guidelines for Trauma-Informed Behavior Management in Foster Care

I am working on training and materials to adapt the Restorative Approach for foster parents. As one piece of it, I am developing Behavior Management guidelines for foster families. The guideline will be meaningless unless embedded in a training program that teaches how to understand trauma, how to help children heal, understanding symptoms as adaptations, the use of the relationship, and taking care of ourselves. However, I do think it will be useful to give parents specific ideas about what we expect them to do. Here is what I have so far, and I would greatly appreciate feed back. Just click the word "comment" below. Thank you.

1. This approach to behavior management is based on the understanding that problem behaviors are the child’s attempt to manage intolerable emotions such as fear, despair and hopelessness. Because the child does not trust relationships and thus has trouble asking for and accepting help; because he or she has an overly activated nervous system; and because he or she has not learned emotion management skills, the child reacts to set backs with behaviors that help in the moment but have long term negative consequences.

2. The most powerful way to change behavior will be through forming strong relationships, creating attuned communication, creating a sense of self worth, and modeling and teaching emotion management skills.

3. Interactions with the children should be consistent with the Restorative Approach. They should display the qualities of playfulness, love, acceptance, curiosity, and empathy. (Daniel Hughes)

4. As the child begins to feel safe, her need for problem behaviors will decrease.

5. Behavioral difficulty should be handled through re-direction and persuasion. Consequences should not be threatened or imposed except as a last resort.

6. Children can be kept closer in (i.e. kept to house, in sight of parents) when they have acted out, but should constantly be re-evaluated as to whether this is still necessary.

7. Points Levels and behavior charts are not used.

8. As soon as the child is back on track after any incident, they should resume normal activities.

9. Children who are having difficulty should be kept closer to parents. They should not go on trips or off on their own.

10. When a child is agitated, escalated or out of control, all parent efforts should be directed towards helping them calm down. This can be done through listening, validating, taking a walk, quiet, adult closeness and calmness. There should be no discussion at this time of consequences or better ways to handle things. These can be discussed later when the child is calm.

11. If a child has a major problem, they should be given a restorative task consistent with the problem they had. The task should include the elements of learning, making amends and reconnecting. In other words, they should be given opportunities to repair damage done, make amends to people hurt, restore damaged relationships, and do something nice for the family.

12. Until the child has completed their restorative tasks, they should not participate in extra or just-for-fun activities. They should be part of all regular activities. This means all regular therapy and school unless parents determine it’s unsafe for the child to be in these activities. They could go to bed earlier to get energy for their restorative work.

13. When the child has completed their restorative task, they should return to all normal activity.

14. Isolation to any room should not be used. Children become regulated in the presence of regulated adults.

15. Restrictions can be used (car, pool, etc). These are used when a child abuses the rules around activities to the point where safety is compromised. They should be for short times such as a day or two and constantly reevaluated.

16. Children can be asked to leave the family area to calm down or re focus, and then return in a short time (5-15 minutes), but this should be done only rarely- children are most likely to calm down when close to calm adults, not when sent off by themselves.

17. Structure is extremely important and the children need a highly structured day with planned activities, and they are helped by knowing what will happen next. Families maintain order throughout the day by such mechanisms as plans, describing what will happen next, taking turns, quiet time, and game playing. Alternating quiet activities with more energetic activities helps the kids contain their emotions. When kids are unsafe, keeping them to a small circle of activities and people is helpful; taking them to events like large family picnics may be a set up for difficult behavior. Choices should be limited. Free time, alone time, and going to bed are particularly difficult and should be supported by the adult. Events in which there is a lot of noise, confusion and stimulation (such as shopping) can also be difficult for some children. The adults should try to structure the child’s day so he experiences success, not put him in situations for which he is not prepared. Routines, rituals and ceremonies are very helpful in establishing a safe structure in the home.

18. Bedtime and hygiene are particularly sensitive times for children who have experienced trauma. Problems in these areas should not be addressed through punishments or rewards. The children should be supported through parent closeness and creative interventions such as music, night lights, bubble baths, etc.

19. When a child’s behavior begins to deteriorate, the first question to ask is: is she feeling safe? The second question is: is she over stimulated?

Thanks again for any ideas or suggestions you may have.

The Talk

I am beginning to work on an adaptation of the Restorative Approach for foster parents. As part of that project, I have been re-reading Dan Hughes latest book:

Attachment Focused Parenting (Daniel Hughes W.W. Norton & Co.; 1 edition March 16, 2009) particularly the last section on reducing attachment resistance. I came across the following section:

"Many children who resist turning to their parents for both safety and exploration of the self and the world tend to develop similar strategies for self-reliance and coping. These strategies reflect the psychological reality that they are responsible for both their own safety and for learning about the world. They... cannot rely on their parents.. They tend to tell other- including their parents- what they are convinced is best and what others should do. They tend to want to decide the best course of action for themselves and to oppose the decisions of their parents and others.

These children also try to avoid any event that might be associated with prior events involving fearful and shaming experiences. They develop a strong avoidance of memories of those prior events as well as any current situations that might elicit those memories. These children, in a fundamental way, may never feel safe since they fear parts of their own mind. Not only are they hyper vigilant about external events, they are equally hyper vigilant about allowing parts of their inner life to enter awareness. They often react with intense rage or terror when seemingly routine events- associated with past traumas- elicit an intense emotional response. Parents may facilitate perceived safety by controlling what their child is exposed to in the external world. It is much harder for parents to increase their child’s sense of safety when his fears originate within himself.

Given that these children have not relied on their attachment figures in any consistent manner, they are also likely not to show the developmental skills that children with attachment security tend to manifest. Their emotional experience and expressions tend toward the extreme, lacking a "thermostat" that will create flexible regulation. Their ability to reflect on the events of their lives tends to be weak, as they react to situations, often in a repetitive and rigid manner driven by fears regarding safety." (p. 177)

I think the idea of the traumatized child being afraid of what is inside himself has profound implications.

To further quote Daniel Hughes:

"Without attachment security, a child is less likely to turn to his parents for guidance as to how to be successful. He is also less likely to acknowledge his mistakes and try to correct them. He is less likely to communicate his difficulties and ask for help. As a result, he is less likely to learn from his mistakes and so correct them. Rather, he is more likely to make the same mistake again and again. This most likely will create a pervasive sense of failure. Rather than ask for help, he is likely to rely on himself more, become even more hypervigilant and controlling. With structure, supervision and limited choices, his environment makes success more likely and failure more difficult. Until he can learn from his mistakes, they have to be kept to a minimum by his environment.

There are many different reasons why children who resist attachment have trouble learning from their mistakes. First, their pervasive sense of shame causes them to deny mistakes, have excuses for them, or blame others. Second, they often have developmental disabilities that place them in situations that they are not prepared for. They tend to be raised or taught according to their chronological age rather than their developmental age. Basic skills of self-direction, impulse control, frustration tolerance, and delay of gratification tend to be weak, leaving them at a high risk for failure in many situations." (p. 185)

This seems to me further illuminate the problems that occur when staff in treatment programs try to talk to kids about their mis-behavior. Staff then say: "He will never take responsibility for his behavior" and are disappointed when the children don’t change. So we have scenarios like this:

Staff is approaching Mark to discuss what happened in school today:

Mark is new here but I really like him. I know he’s has had a rough life
Still, he can’t go around hitting people like he did in school today.
I have to get him to understand what he did wrong and take responsibility for his behavior.
I know Leroy can instigate other kids.
I will explain to Mark that if he just asks staff for help when Leroy bothers him things will go much better.
I will explain that if he doesn’t hit anyone for the rest of the week he can go to the movies with us on Saturday.
At first I didn’t think he was listening but then he began to agree with what I was telling him.
I’m sure the rest of the week will be better.

Mark is being approached by staff with a serious look on their face:

Someone is coming towards me. She looks angry. Danger! Danger! Mobilize all defenses!
I don’t trust her. I just met her a few weeks ago and she seems mean.
I know I screwed up in school again today, what a total loser I am, but the class was so confusing and I didn’t get the math. The teacher was busy with the other kids as usual and besides I know she doesn’t like me. Leroy was giving me that smirk like Joe used to and what could I do but push him away and I was afraid I was going to do much worst things.
She’s coming over here to kick me out or punish me or something bad I know it I know it.
La la la la la la I cannot hear a word she is saying who cares it doesn’t matter
I tell her what happened was Leroy and the teacher’s fault and this place sucks and I hate everyone here.
I try to shut out her words, she is smiling but I know that is fake. I agree with whatever she says trying not to hear it. I have my own ways of protecting myself against Leroy.
FINALLY she is going away and I can get back to my Nintendo DS

Sound familiar?
Will the rest of the week go better?

What could the staff have done differently:
Take longer to connect before going into the problem.
Identify the feelings Mark must have had in school and emphatically validate them.
Understand the math difficulty, get the teacher’s help.
Connect with Mark around how scary this place is.
Apologize that the staff didn’t see he was having trouble.
Hope that he will be able to trust them enough to tell them when he gets upset.
Meanwhile say they will look out for him and try to be more alert for when things go wrong, he is over whelmed or other kids are getting on his nerves.

Maybe it sounds too hard or too much time or a luxury- but dealing with the fights and restraints that could emerge from this scenario takes a lot of time.

And doesn’t Mark have to learn that hitting is wrong and he should take responsibility for his actions?

No, he has to learn that not understanding the math doesn’t mean you are no good and that someone can assist you, that he can trust people, that adults will help him, and how to notice when he begins to feel frustrated and upset and what to do to calm himself down.