Tag Archives: Children & Adolescents

Handle with care: Addressing child trauma in West Virginia

By Bethany Bray May 5, 2015

“Their normal is chaos, and we have to bring calm.”

For public school students in West Virginia, the calm therapist Felicia Bush is referring to comes in the form of an innovative, multidisciplinary program that aims to identify and treat trauma in real time.

Bush, a provisionally licensed social worker with a master’s degree in counseling, provides trauma-focused therapy for youth in the public schools through the Defending Childhood Initiative (DCI). The program brings together law enforcement, public school staff and mental health professionals to create a HandleWithCaresafety net for youngsters, bridging the gap between what happens at home and the hours they spend at school.

For example, a child might witness police responding to a domestic violence incident that occurs in the home in the wee hours of the morning. Through DCI, police officers are trained to note whether a child was present during such incidents. Officers then find out what school the child attends and file a “handle with care” notice with the school. The one-page form doesn’t provide details about what happened but simply lets the school know that the student may need extra attention.

“The child sometimes discloses what happened but not always,” Bush says. “You don’t have to know what happened. You just have to know that something happened that potentially can affect the child’s ability to learn.”

In other cases, a parent or caregiver might alert the school that something is going on at home, such as a parent’s impending military deployment or the death of an extended family member.

After being alerted, DCI’s network clicks into place to provide whatever extra care the child may need at school — from a space to shower, nap and change clothes to a chance to retake a test to recurring sessions with a trauma-focused therapist.

Law enforcement personnel and entire school staffs — from principals to the cooks in the cafeteria — complete DCI training to help them identify and be sensitive to child trauma. The initiative is designed to stem both the short-term and long-term effects of trauma, especially its impact on children’s ability to learn.

“Trauma is a public health issue, not just a counseling issue,” says Carol Smith, a licensed professional counselor (LPC) and member of the DCI advisory board in West Virginia. “[Addressing this] is a huge paradigm shift, and it’s going to take all of us.” That includes medical and mental health professionals, educators, law enforcement personnel, religious leaders and others in the community, she says.

 

Getting started

The DCI in West Virginia is a localized version of a program first introduced by U.S. Attorney General Eric Holder. He launched DCI in 2010, prompted by the plentiful research showing that trauma affects a child’s ability to learn and is associated with long-term physical and mental harm.

In West Virginia, U.S. Attorney Booth Goodwin has overseen the launch of a DCI program tailored to local needs, including creation of the “handle with care” form used by law enforcement.

A group from the Child Witness to Violence Project, a successful multidisciplinary trauma-focused program in Brockton, Massachusetts, came to West Virginia in 2011 to train DCI participants before the program launched in pilot schools, according to Tracy Chapman, the victim witness coordinator in the U.S. Attorney’s Office for the Southern District of West Virginia.

“We looked at what works, and we looked at the needs of West Virginia — the needs that are impacting our children, our classrooms,” she says.

The first pilot schools in West Virginia adopted the program in 2013. In less than two years, law enforcement personnel have recorded 414 incidents involving 768 children through DCI, according to Charleston Police Lt. Chad Napier, a coordinator for the program.

Now, after its success in five different pilot schools at the elementary, middle and high schools levels, the stage is being set to roll the DCI program out statewide.

This spring, it was announced that the DCI program will now be headquartered in the newly created West Virginia Center for Children’s Justice, located at a state police facility in Dunbar. This change will allow DCI to be more easily implemented statewide while adhering to a consistent model, Chapman says.

“We can no longer work in our silos focused on one piece of a child’s life puzzle. We must work together to make systemic improvements that can truly change the trajectory of a child’s path,” Goodwin said at the center’s unveiling. “… This [Center for Children’s Justice] will improve communication and collaboration between law enforcement, prosecutors, schools, advocates and mental health providers, and help connect families, schools and communities to mental health services.”

Goodwin has been the driving force between DCI in West Virginia, making it a personal priority, Chapman says. “As a federal prosecutor, we can’t arrest our way out of crime and the types of problems that are affecting our communities,” she says. “We have to provide the resources to children and to communities and to schools to actually change and break the cycle. We have to intervene early, and we have to intervene effectively with kids to help keep them on the right track. That’s his [Goodman’s] message.”

 

Creating a safety net

Through DCI, school staffs work to provide as much specialized care as possible for trauma-affected children, such as partnering them with a mentor or ensuring that they can make up missed homework. The school counselor plays an integral role in these efforts, from readying a schoolwide traumatic crisis response plan to identifying children and families who could benefit from extra mental health support, says Smith, a member of the American Counseling Association and president of the West Virginia Counseling Association.

When children affected by trauma need extra help beyond what the school can provide, they are referred to mental health practitioners who provide in-school therapy as part of DCI. All of these practitioners are specially trained to treat trauma. One of DCI’s pilot schools, an elementary school in Charleston, has established a permanent mental health clinic in the school.

“[DCI] gives services to the child immediately upon the experience of a potentially traumatic event. If it’s needed, the service is there, and there’s no stigma to it,” says Bush, executive director of Harmony Mental Health, a nonprofit mental health and social services agency based in Parkersburg.

Prior to the launch of DCI, Bush says, school staff members had to guess when something had happened in a child’s life outside of school, clued in by sudden behavior changes or when Child Protective Services personnel came to the school — often weeks later — to ask the child questions. Now the initiative is allowing professionals to help students deal with trauma in its immediate aftermath.

Professionals involved in DCI agree that the program is helping to reach students who might have previously fallen through the cracks and not been identified as needing help. “A lot of these kids were never on anyone’s radar unless they were a direct victim,” Chapman says.

 

A culture of safety

In addition to providing extra help for individual children, the DCI program trains educators to introduce schoolwide initiatives that focus on mental health.

In one example, the school principal and other staff members greet students coming off the bus each morning. The students are asked to give a thumbs up or thumbs down, depending on how they are feeling that day. The principal uses this to gauge the school population’s overall climate for the day and tailors the school day accordingly. On “thumbs down” days, this could include having a therapy dog visit the school, postponing testing or introducing extra small group counseling sessions with a school counselor.

A similar initiative is introduced for classrooms. Upon arriving, students are asked to take a marble and place it in a bowl. They select a green marble if they are feeling OK and a red marble if they are feeling bad. The teacher can gauge the classroom’s needs by checking the bowl, adding extra wellness initiatives to the day such as breathing exercises or playing soothing music in the classroom (see sidebar, below).

The program also requires a provider of trauma-focused cognitive behavior therapy to be available at each school, Chapman says.

Individual children who are referred to mental health practitioners through DCI are given an initial screening to see whether they need general counseling or trauma-focused counseling, Bush says. If the case does involve trauma, the therapist will go over a treatment plan with the child’s parent or caretaker.

In addition to trauma-focused cognitive behavior therapy, the mental health practitioners provide lots of psychoeducation, Bush explains. DCI therapists work to help the children understand what trauma is and guide them in learning coping mechanisms, including the management of behavior, anger and emotions.

“Some of [these children] have no ability to identify or control their emotions,” says Bush, who has worked with victims of domestic violence and trauma for more than a decade. “The goal is to help them identify the trauma they’ve experienced, put it into a narrative and begin to express it so it doesn’t affect them for their whole lives.”

Because the therapy is conducted in the schools, mental health practitioners are able to collaborate with school staff, check in often with the children’s teachers and see the students “in context,” Bush says. The mental health practitioners often visit a child’s classroom, the lunchroom or a gym class just to observe the child in a group setting. “We do a lot of listening,” Bush says.

By being so ingrained in the schools, the therapists are also able to schedule therapy around field trips and other events the child would not want to miss, Bush says. Teachers have been very willing to work with Bush and her therapist colleagues, she says, even participating in department and individualized education plan (IEP) meetings when asked.

One of the most helpful aspects of the DCI program is that the children “realize they’re important to us [the adults], to the school and to all the people who have put in extra effort to make this available for them,” Bush says.

 

It takes a village

The DCI program brings together professions that were not always good about communicating with one another, Chapman notes. “Unfortunately, for far too long we’ve all worked in our individual silos. Children do not live in silos. They live in all of our worlds,” Chapman says. “… For far too long we haven’t communicated and collaborated and broken out of our silos to make sure that we’re comprehensively addressing the needs of the child. For far too long these kids have fallen through the cracks.”

Chapman and Bush both use the metaphor of putting pieces of a puzzle together to describe the program’s multidisciplinary approach.

“We all have a little piece of the puzzle, a little piece of a child’s life,” says Bush, adding that anytime those puzzle pieces are connected, it benefits the child. “We’re blurring the lines for the benefit of the child. Not the lines of confidentiality or procedure, but making the community safer by providing a safety net for children so they’re not the next generation of perpetrators or the next generation of adult victims.”

Treating the effects of trauma in young children “is the only place we can truly change the cycle of violence in our community,” she says.

DCI stakeholders — including law enforcement personnel, public school representatives, mental health providers and community partners such as social service agencies — meet often to review and evaluate the work being done.

In some ways, the program’s training has also ushered in a cultural shift, Chapman says, in part by introducing a level of care and follow-up that didn’t often exist previously in the state’s law enforcement. New protocols guide police to avoid making arrests or interviewing witnesses in the

Blackwater Falls State Park, West Virginia

Blackwater Falls State Park, West Virginia

presence of children whenever possible and to make regular, noncrisis visits to local schools.

“There’s a whole new culture and mindset in the police department that they need to recognize when kids are present [during an incident] and the potential impact that could have on the child,” Chapman says.

 

In your neighborhood

DCI was launched in some of the neediest schools in West Virginia. At the program’s first pilot school, an elementary school in Charleston, 93 percent of the students are from low-income families. But those involved in the initiative agree that DCI’s multidisciplinary approach is needed everywhere as well.

All communities have children and households that are affected by trauma, Chapman notes. “We all have to think differently. … If we continue to do the same things we’ve always been doing, we’ll continue to get the same results. That goes for schools, mental health [practitioners] and law enforcement,” Chapman says. “Counselors play a vital role in this process as well. … I would encourage mental health providers to think outside of the box [and] understand the limitations that some families have with coming to their offices [outside of the school day].”

“People don’t exist in a vacuum of 50 minutes” — the length of a typical in-office counseling session, agrees Bush. “You want to send them out into as much support as you can possibly garner on their behalf. If you want [clients] to be successful, it’s a no-brainer. Make yourself familiar with all the [support] systems that are available.”

The collaborative work being done in programs such as DCI involves going the extra mile, but it’s well worth it, Bush says. “Step out of your comfort zone and you will have a richness of experience that you can’t imagine,” she says, her voice breaking with emotion. “Open up your world to experiences, people and situations that you wouldn’t normally experience. It’s just such a growth experience for everyone.”

DCI also models what adults regularly try to teach children: to be cooperative. “[Students] see adults working together not in a negative way, but in a healing way,” Bush says.

Both Chapman and Bush stress that communities interested in DCI should adopt the program as a whole. It doesn’t do any good to have law enforcement record and refer children involved in traumatic incidents unless a trauma-sensitive network is set up in the community’s schools, Chapman asserts.

“It takes all these components working together to get this initiative to succeed,” Bush agrees. “It’s important that [communities] don’t piecemeal it.”

 

Meeting a need

Through her involvement in DCI, Smith has decided to devote the remainder of her career to focusing on trauma. At Marshall University, where she is an associate professor of counseling, Smith is involved in the launch of a graduate certificate program in violence, loss and trauma counseling. In addition, several Marshall University counseling interns have been involved in DCI under Bush, Smith says.

“When your eyes are opened to trauma, you realize it’s everywhere. Everyone who walks through your door has it, and if you don’t handle it correctly, you can restigmatize or cause harm,” Smith says. “Counselors can become change agents in the community. … The field is waking up and becoming savvy to the issues that are swirling around us. Yes, it’s exhausting, but it’s worth it.”

 

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Learn more about DCI in West Virginia: handlewithcarewv.org

 

Much of DCI’s schoolwide trauma training is adapted from the book Helping Traumatized Children Learn, a publication of the Massachusetts-based Trauma and Learning Policy Initiative. Find out more, and download the book for free, at traumasensitiveschools.org.

 

 

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Classroom initiatives for “thumbs down” days

What should happen on days when the majority of students indicate that they’re not OK? The possibilities are limitless, says Carol Smith, a licensed professional counselor, member of West Virginia’s Defending Childhood Initiative advisory board and president of the West Virginia Counseling Association.

Examples of activities to calm and refocus students include:

  • Doodle-quilts: Each child is asked to take out a 4-by-4-inch piece of paper (already cut and available for such a time as this) and to spend five minutes quietly doodling on it in whatever colors the child chooses. Students then pass the pieces of paper to the front of the room. The teacher tapes the pieces together and posts the “quilt” of doodles on a bulletin board, observing that the doodles show the students’ “processing” of whatever caused the heated (unhappy/stressed) temperature.
  • Round robins: Children sit or stand in a circle, facing each other. With the process explained and structured by the teacher, each child, in order, identifies one thing that is on his or her mind. The teacher summarizes, validates, encourages and then redirects the children to the work at hand.
  • Stand up and stretch: The teacher validates the students’ collective temperature and provides structure: “We are going to breathe a few breaths and do a few stretches to process our feelings, and then we’ll get to today’s lesson.” The teacher takes students through a couple of deep breaths and a short series of stretches to allow students to “reboot.” The verbal validation, structuring and limited activity work to restore equilibrium and allow students to get back to business.
  • An agreed-to, brief regrounding ritual that has been previously co-constructed by the teacher with the children, typically at the beginning of the school year.

Source: Carol Smith, associate professor of counseling, Marshall University

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

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Assessing ‘ideal’ versus ‘real’ family characteristics with adolescents

By Brandon S. Ballantyne April 13, 2015

When working with adolescents in a group setting, it is important to provide opportunities to explore, evaluate and process the dynamics that occur within their homes. After all, eventually they will be faced with the dilemma of figuring out how to apply what they have learned in therapy to situations at home.

I have formulated a creative, psychoeducational task that allows adolescents to assess and explore the similarities and differences between their “ideals” and what really occurs within their unique and, at times, chaotic family relationships. I have broken this down into three simple categories. I ask the housedrawing_1adolescents to draw an illustration of a house. Inside the house are to be three distinct rooms with boundaries, because boundaries are healthy no matter how you slice that pie. The adolescents usually laugh at that analogy. Utilizing that humor, I then invite them to talk more about the boundaries at home.

I next ask them to label each of the three distinct rooms in the house. One section is labeled “Think,” another section is labeled “Do” and the last section is labeled “Say.”

I ask them to title their paper “Family Shoulds.” As a group, we discuss what the word “should” refers to. Typically, one group member will mention his or her impression of the word “should” as a reflection of a demand, expectation or wish. All of those definitions are acceptable for this task.

The idea is to have each group member write a list of three items for each category inside the house: three things they believe a family “should think,” three things they believe a family “should do” and three things they believe a family “should say.”

I have found that when I simplify group tasks in terms of “threes,” that the group flows more smoothly. For example, three rooms in the house and a list of three items for each of the three categories. I think this provides the task a sense of organization and predictability, thus increasing the group members’ level of trust and safety. This creates a less intimidating environment for each group member to talk about his or her family issues or other issues that may come up.

It is important to invite each group member to ask questions about the assignment. For example, I usually receive questions such as “What do you mean by things a family should say?” You might encourage the adolescents to write down specific things they believe a family should say to one another and then apply this to the other categories as well. For example, you might encourage the adolescents to write down three things they believe a family “should do together.” Or encourage them to write down a list of three things they believe a family “should think about one another.”

In the second component to this task, you instruct each group member to draw another outline of a house with the same three categories: think, say and do. Except this time, you ask the adolescents to write down their beliefs about their “Family Reals.” It is important to have a discussion about what you mean by the term “reals.” Usually, one group member will suggest that “reals” refers to facts or reality.

As the counselor, you can then take the focus of the group and place it on sharing ideas of “what actually goes on” from day to day in their families. Discuss how this is similar to or different from their beliefs about what a family “should” be doing, thinking, or saying.

This invites conversation about specific issues within their families that the adolescents want to address. You can also have a discussion about what “shoulds” are healthy versus what “should” are unhealthy. Finally, you can discuss which “shoulds” are realistic to address, identifying achievable, measurable steps to work toward at home.

As the adolescents listen to the other group members speaking about their family issues, they beginhousedrawing_2 to feel a sense of validation and belongingness. They cultivate a belief that “I am not alone.” As anyone who has studied Irvin Yalom likely knows, these three components are critical to the progress of individuals in group settings.

This task can also be used as a tool in family therapy sessions, serving as a less intimidating way to open the door to communication. It can be used to explore and address each family member’s expectations for others in the family unit.

It can be emotionally difficult for adolescents to talk directly about family issues. But as a counselor, I believe that if you can access adolescents’ creativity and provide a level of predictability, organization and safety, it will open the door to communication between you and your client. This can then be transferred to work with the family as a whole.

I believe this task creates opportunities for individual growth within the therapeutic relationship and opportunities for growth within the family system by reinforcing the difference between realistic and unrealistic expectations, discussion of problem-solving and implementation of communication skills.

 

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Brandon S. Ballantyne is a licensed professional counselor, national certified counselor and certified clinical mental health counselor. Contact him at ballantynebrandon@yahoo.com.

 

 

Empowering youth victimized by cyberbullying

By Janet Froeschle Hicks February 25, 2015

JF_HicksTechnology has changed the way adolescents bully one another. What once happened during an eight-hour school day now happens online within the home environment. This form of bullying is inescapable and occurs at all hours of the day and night. For victims, the consequences of being targeted by this behavior can range from lowered academic achievement to mental health issues such as anxiety, depression and even suicide. When assisting victims of cyberbullying, I find a combination of principles from Rudolf Dreikurs’ mistaken goals, Betty Lou Bettner and Amy Lew’s Crucial C’s, Alfred Adler’s social interest and Steve de Shazer’s solution-focused brief therapy to be helpful.

Dreikurs contended that children mistakenly seek out attention, power, revenge and inadequacy in lieu of healthy personal goals. This might explain some of the behavior associated with cyberbullying. For example, adolescents might bully one another to gain attention or power from others. The victim may then choose to perpetuate the behavior by seeking revenge or choosing a stance of inadequacy and hopelessness.

Fortunately, Bettner and Lew describe four Crucial C’s that I find helpful to positively displace a youth’s mistaken goals. These Crucial C’s consist of feeling connected, feeling courageous, feeling capable and feeling that you count (or are important). In my opinion, shifting the focus from Dreikurs’ mistaken goals of revenge, power, attention and inadequacy to those of courage, capability, connectedness and importance may change the outcome of cyberbullying from victimization to empowerment. This change of focus could alter the cycle of cyberbullying so that victims do not choose revenge and therefore avoid becoming perpetrators themselves. Additionally, victims become focused on improving internal characteristics and, in turn, enhance mental health.

Adler’s social interest may be used to further reinforce these Crucial C’s. Victimized youth who become involved in helping others demonstrate courage as part of initial engagement and experience connectedness as a result of their community involvement. Furthermore, I believe they experience a sense of counting or importance as a result of their contributions, as well as self-evidenced proof of their capabilities. As youth victimized by cyberbullying experience these Crucial C’s firsthand, they become empowered and feel more in control of their feelings and reactions. Self-efficacy and self-esteem begin to replace anxiety, depression and hopelessness.

The theoretical principles mentioned above become even more productive when combined with de Shazer’s solution-focused brief therapy techniques to assist victims of cyberbullying. Complimenting youth when they avoid mistaken goals and demonstrate positive attributes and behaviors builds a foundation on which courage can thrive. Instead of exhibiting retaliatory behaviors, the victim of cyberbullying may exhibit developmentally appropriate coping skills. According to de Shazer, complimenting involves pointing out a person’s strengths so that self-efficacy is instilled and recognized. Exception questions allow victimized youth to uncover times when they responded to difficult times without negative behaviors or emotions. This encourages a focus on what works rather than replicating self-defeating mistaken goals and behaviors. Solution-focused brief therapy feedback allows the counselor to reinforce the client’s strengths at the end of a session, connect ideas by agreeing with the client’s stance and suggest a task for the client to undertake.

In short, a synthesis of Dreikurs’ mistaken goals, Bettner and Lew’s Crucial C’s and Adler’s social interest with de Shazer’s solution-focused brief therapy techniques may empower victims of cyberbullying and improve their mental health. The case of “Elizabeth” that follows illustrates how I specifically combine these elements within a counseling session.

Case study

Elizabeth is a 14-year-old high school freshman. Her teacher referred her to the school counselor because her grades are falling and she is skipping classes. Not surprisingly, Elizabeth reveals that she is spending most of her nonschool time communicating with others through social media. It doesn’t take long for the counselor to discover that another girl is cyberbullying Elizabeth. Elizabeth indicates that her self-esteem has fallen, and she thinks about the social fallout constantly.

Because Elizabeth’s self-esteem and grades have declined, she needs to believe that she is capable of succeeding and that she has value (or that she counts). At the same time, she requires the courage to overcome feelings of inadequacy, thoughts of revenge and a desire for power and attention. The connectedness she already possesses with friends and family may help Elizabeth overcome some of the negative feelings associated with being cyberbullied.

To accomplish this in the counseling session, I use a five-step model:

1) Build rapport

2) Identify and express emotions

3) Integrate feelings and experiences

4) Develop coping strategies

5) Administer feedback

The initial use of solution-focused brief therapy may be effective in building rapport with Elizabeth and changing the overall tone of the session from a focus on the negative to a more positive position. Elizabeth needs to be genuinely complimented so that she minimizes feelings of inadequacy and refocuses on her personal strengths. Asking Elizabeth exception questions helps her to focus on instances when she has been successful. When followed by solution-focused complimenting, this also helps her to reframe the situation and begin to feel empowered.

Next, Elizabeth must identify and express the emotions she feels at home, at school and online. To accomplish this, I ask Elizabeth to describe how she feels in each setting and to associate a color with each feeling. Next, I have her draw a line using a different colored marker for each emotion on three separate pages (school, home and online). Each colored mark is labeled and discussed as a representation of an emotion she feels within that particular setting. I then use solution-focused brief therapy complimenting and exception questioning techniques to demonstrate ways in which Elizabeth is positively handling these emotions. Pointing out times when Elizabeth has handled similar emotions adequately ensures a focus on her strengths and a repetition of the Crucial C’s as demonstrated in her response behaviors.

To integrate feelings and experiences and to expand on ways that Elizabeth is demonstrating the Crucial C’s, I find it helpful to assist her with associating mistaken goals and the Crucial C’s. When shown separate index cards, each containing a written mistaken goal, Elizabeth reads the word and describes a time when she experienced each feeling. For example, Elizabeth might read the word inadequacy and say, “I feel inadequate every time that girl posts something about me.” Or Elizabeth might say, “The word revenge reminds me of the time I got even with her by telling lies about her to others.”

After Elizabeth elaborates and finishes the story, I ask her to tell me which of the Crucial C’s she needed to improve the situation. She then retells the story using the selected Crucial C. For example, Elizabeth might retell the story about revenge with a new focus on courage and connectedness. For instance, “That girl said I was ugly, but instead of making up lies about her, I logged off and texted my best friend. We talked about other things until I forgot all about it. It took courage not to get even, but because I have other friends, I was able to do it.”

Finally, I ask Elizabeth to generate short-term and long-term coping mechanisms. Exception questions help Elizabeth recognize and generate this list of ways she has previously coped in similar situations. These strategies may include creating art, journaling, playing video games, playing with pets, exercising or participating in sports, playing or listening to music, doing guided imagery, visiting with friends, talking to parents and numerous other ideas. To strengthen her long-term coping strategies, I ask Elizabeth to find a social interest activity. Suggested activities include mentoring younger children affected by cyberbullying, creating safety tips for children who surf the Internet, reading empowerment stories to younger children, reading to or visiting elderly adults, volunteering to work in community agencies and countless other possibilities. I then ask Elizabeth to contemplate these ideas, generate a list of both short-term and long-term coping strategies to use during the next week and return to the next session with social interest ideas.

At the end of the session, I incorporate de Shazer’s solution-focused brief therapy feedback technique. I compliment Elizabeth once again so her strengths are evident to her as she leaves the session. For example, I might say, “I recognize the courage it took to share all of this with me this week. I think that shows you have strengths to help you get through this.” Then I might add, “I agree that you need to feel better about yourself. Over the next week, I suggest using the short- and long-term coping strategies you listed as well as finding a project to help others while helping yourself.” To conclude, I ask Elizabeth to report on her success at the next session.

Subsequent sessions focus on self-reported improvement and implementing social interest activities. There is also continued focus on implementing the Crucial C’s in lieu of mistaken goals. Solution-focused brief therapy techniques, including complimenting, exception questions and feedback, are used throughout all sessions to continue reinforcing Elizabeth’s strengths. Finally, I incorporate Internet and online safety and social media trainings for Elizabeth and educate her parents on what Elizabeth is experiencing all day, every day online.

Why include parents?

Parents are included in future sessions for several reasons. First, upon hearing about cyberbullying, many parents fear the Internet and insist that their children avoid all technology. Although this may be an effective short-term solution, I do not believe it helps long term. Eventually, youth find themselves required or tempted to use the Internet for employment, homework or socialization.

As a result, I teach Internet and online safety skills both to parents and youth. These safety tips provide education about privacy and restraint when posting online, decrease fear and allow youth to continue using the Internet provided that their parents are involved in Internet communications. Youth and parents must understand the importance of keeping specific personal information private as it relates to the long-term and worldwide reach of the Internet. Once parents understand how to use social media appropriately, they have an opportunity to become role models for the proper use of technology. Learning strategies to avoid harm while using the Internet may be an important mechanism for personal empowerment for both victims of cyberbullying and their parents.

Another reason counselors should involve parents is related to the mistaken goals discussed earlier. Initially, parents often respond to their child’s victimization with inappropriate feelings of attention, Branding-Box-Cyberbullyrevenge, inadequacy and power. These feelings could result in parental behaviors that perpetuate bullying rather than improving the situation. For example, some parents initially respond to knowledge that their child is being cyberbullied with feelings of revenge. These parents may confront the bully or the bully’s parents and unknowingly increase, rather than decrease, their child’s victimization.

I teach parents to first empathize and communicate with their child. It is important that any parental response to bullying first be discussed with the child. If nurtured, the bond between parent and child may become the greatest protective element for youth who have been cyberbullied.

Conclusion

As Elizabeth experiences the Crucial C’s firsthand through social interest, feels secure in the bond with her parents and focuses on her strengths, she begins to feel empowered rather than victimized. Internet safety tips that illustrate the importance of privacy and restraint when posting online further demonstrate to Elizabeth that she possesses courage and has control over life events. Eventually, Elizabeth is able to focus on her own value rather than on the unhealthy stigma perpetuated by others.

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Janet Froeschle Hicks is an associate professor of counselor education and chair of the Educational Psychology & Leadership Department at Texas Tech University. She is both a licensed professional counselor and a certified school counselor in Texas. Contact her at janet.froeschle@ttu.edu.

Charles R. Crews, associate professor of counselor education at Texas Tech University, also contributed to this article.

Letters to the editor: ct@counseling.org

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Case study: The critical need to conduct thorough child assessments

By Gregory K. Moffatt January 29, 2015

“Amanda” sat on the couch across the room from me drawing on a sketch pad. A lovely young girl of 14, she weighed scarcely 100 pounds, and with her cheery and naïve smile, she looked as innocent as they come. If I hadn’t seen attachment disorders many times before, I could easily have been swingsfooled by her carefree air and seemingly open-book candor.

Could this barely pubescent teen really have done what she had been accused of? In my work, I have seen dozens of children who have been accused of animal cruelty, rape and even murder. I knew better than to be fooled by the crafty façade of which children such as this are capable.

 

The case

The call on my cell phone was from a social worker at a foster care agency. As I drove through Atlanta traffic, she explained that two family pets had been horribly violated in a sexual way, with injuries so serious that both dogs had required surgery. The county sheriff’s department was investigating the case, and Amanda was the prime suspect.

Amanda’s background was classic for reactive attachment disorder (RAD). Very early in life, she had been abused both physically and sexually, at which time she was removed from her biological parents’ home and placed in foster care. Early attachment problems were present in her case file, including sexual acting out and some indication of cruelty to animals.

Circumstantial evidence pointed to Amanda as well. She was the caretaker of the pets and was often unsupervised. She was the last person seen with the dogs before their injuries, and her home was in a remote, rural area, making it unlikely that some random perpetrator was at fault.

My heart sank. I felt certain I had another case of a seriously disturbed child, and I made an appointment to do an assessment with Amanda within the next few days.

But things are not always what they seem.

 

The assessment

I easily could have conducted my in-office assessment with Amanda, written my report, submitted my bill and been done with it. But this would not have given me the fullest picture of Amanda and the extenuating circumstances this situation presented.

Prior cases such as Amanda’s that I had worked were clear. Children with RAD often begin displaying disturbing behavior in early childhood, sometimes even in infancy. These behaviors become progressively worse until parents or guardians eventually run out of ideas for coping. By the time they come to my office, these children have often sexually assaulted other children, destroyed property or become incorrigible. None of these things were true for Amanda.

My normal assessment includes, among other things, a number of processes that allow me to observe a child’s sexualization, socialization and attachment. In cases such as this, I also normally conduct a minimum of two different assessment appointments. Children may behave very differently from one day to another, and this practice has helped me avoid many problems over the years.

Amanda passed these assessments with flying colors. I was at a loss because cursory information made her the most likely suspect, but what I saw in my assessment was inconsistent with a young teen who could have so cruelly abused an animal in such a sexual way.

Looking through nearly 10 years of Amanda’s evaluations by psychologists, I found hints of sexualization and cruelty to animals as I had initially been told, but careful reading put this information in a different context. In the child’s early years, there had, indeed, been evidence of sexual acting out as one might see in children with RAD. But interestingly, no one had observed even a single instance of Amanda acting out sexually since she was 6 years old —a span of longer than eight years.

The “cruelty” to animals that existed in her file was, in my opinion, either a very mild form of cruelty or not cruelty at all. Children often hurt animals, sometimes in very serious ways, but my concern is not with the seriousness of the injury. A normal child might seriously injure or even kill a pet by accident. A child with RAD, on the other hand, might torment and torture a pet explicitly for the purpose of causing pain, even if the pet doesn’t end up being seriously injured. These are very different motives. I saw no clear evidence of “cruelty” in the recorded behaviors in Amanda’s file.

But this evidence can be deceptive. Children with RAD often mask their cruel behaviors against both animals and people as seemingly innocent mistakes. I had to be certain I wasn’t missing something with Amanda.

 

Interviews and supporting information:

I needed a fuller picture of Amanda than I could achieve from my office evaluation and the information in her file. One of the many professional hats I wear is that of a homicide profiler. When I am looking at a homicide case, I want to know as much as I can, not only about the homicide but also about the victim, the place, the weapon and the timing of the event. I interview as many people as I can and look at every piece of evidence available to me. In ethnographic research, this is called triangulation (looking at evidence from three or more sources), and Amanda’s case demanded this type of multidirectional examination. I didn’t want to make a decision based simply on my office assessment.

I started my interviews with the foster parents. I needed to know more about Amanda’s history in the nine years they had had guardianship of her, and specifically about the past three or four years. This caring and loving couple had treated Amanda like a daughter since her placement in their home, and they were certain she was innocent. I knew they could be biased in their perceptions, but unless they were trained to know what I was looking for, they couldn’t easily manipulate my impressions.

I was looking for any symptoms of sexualization or cruelty in Amanda’s recent history. RAD doesn’t go away by itself, and it doesn’t improve with time. Instead, the symptoms digress. If Amanda had been cruel to animals early in life, she almost certainly would not stop, and the cruel behavior would escalate. Likewise, if she truly was a child with RAD and she had acted out sexually early on, she would still be engaging in sexual behaviors, and those behaviors also would have escalated. Cruelty moves through a digression — objects to animals and then animals to people. Sexual behaviors digress as well — masturbation, sexual exploration, acting out with consenting others and, finally, acting out on others by force.

Children might easily “practice” their sexual exploitation on animals before moving to humans because animals are easier to control. If Amanda had done something so overtly sexual and cruel to the two family pets, there would have to be symptoms of cruelty and sexualization in her recent history. But my interview with her parents turned up no such allegations in any context, at any time, from any teacher, playmate, sibling, coach or therapist.

I was also interested in Amanda’s ability to connect with other human beings — to show and receive affection. Children with RAD have trouble with both. The comments of the foster parents were consistent with what I had observed in my evaluation. Amanda had no troubles connecting in any context — school, church, athletics or home. She seemed to be a loving child who, although socially awkward, got along well with others and would not intentionally hurt anyone or anything.

I also needed the investigative perspective of the sheriff’s deputy, even though I knew he was already convinced that Amanda was to blame. For good reason, he saw no other logical suspect and had focused all of his investigative resources on her, but he was waiting for my evaluation before proceeding. He provided me with the basic facts of the case. During our first conversation, I derived a clearer picture of how this event could have taken place. The timing of events and other facts confirmed the information I had received from the foster parents. This confirmation was very important because it allowed me to dismiss the possibility that they were attempting to deceive me. It also helped me create a visual image of the event and give further consideration to how Amanda might have injured these dogs without being detected as well as how difficult that might have been for her to do.

Armed with that information, I realized it was at least possible that Amanda was just beginning to exhibit cruel behavior. I needed to know what the dogs experienced, so, with the consent of my client, I called the veterinarian who conducted the surgeries. My main question: Would someone have known she was hurting these animals, or would the animals simply have stood still and allowed the abuse? After all, Amanda was tiny, and these were large, full-grown dogs. Could she have restrained them?

The vet said the dogs would have been howling, struggling and whimpering. “No question,” he said. “The perpetrator would have known these dogs were in serious pain.” This was consistent with the idea of children with RAD intending to do harm, but it left me wondering how Amanda could have controlled the dogs long enough to do this.

I wanted a second opinion. I called a university with a respected veterinary program and talked to the department chair. I sent him photographs of the objects used in the abuse and gave him a summary of the case. His answer to my question? The dogs would have simply stood there and accepted the abuse! The perpetrator may not have known that he or she was causing serious, life-threatening pain, he said. This could be consistent with a child just beginning to act out on animals and didn’t exonerate Amanda.

I now had two completely opposing opinions, so what could I do? I chose to dismiss the “pain” component because I couldn’t be certain which veterinarian to believe. What was uncontested was the fact that both female dogs had large objects inserted into their vaginas. This was clearly a sexual behavior. Most adults couldn’t even find a dog’s vagina. The most obvious rear orifice in a female dog is the anus. This told me that this perpetrator had to deliberately seek out the vagina. Therefore, this was almost certainly not the first time he or she had acted out sexually, which was inconsistent with Amanda’s history. Was it possible for a child to go from simple “show me yours” sexual acting out nine years earlier to vaginally violating not one but two animals at the same time? I hardly saw that as possible.

 

Conclusions

After nearly two weeks of study, interviews, telephone calls and assessments, my final conclusion was that Amanda had nothing to do with the abuse to these animals. I believed that the loving and caring foster family had helped her weather a very difficult start to her life and their interventions had been effective in counteracting the problems of early attachment issues. Amanda measured low normal in IQ, and it seemed inconceivable to me that she could be cunning enough to hide this type of serious dysfunction from everyone in her environment for so long. Although it wasn’t impossible, it was highly improbable.

It was my recommendation that the foster care agency carefully investigate other possible perpetrators among the children in the home and that the sheriff’s department look into other possible suspects from nearby homes as well as hunters or others who might be known to be in this remote area. In my final telephone call with the investigating officer from the sheriff’s department, he asked me the obvious question: “If this child didn’t do it, then who did?” Occam’s razor tells us that the simplest solution is most often the correct one. That just wasn’t the case here. I didn’t want to sound trite, but the person he should investigate really wasn’t my problem, and I said so, although not so bluntly.

Still, I remained tentative in my final evaluation. The risk to others was very high if I was wrong. Therefore, I proposed that Amanda be reevaluated at six months, and I also recommended that she be evaluated by an expert in dissociative identity disorder (DID). The only way I could fathom her possibly committing such acts and yet successfully hiding them from everyone for so long was the remote possibility of DID. I suggested that either I was right and Amanda had nothing to do with this incident, or I was wrong and she was the most clever, sly and dangerous child I had ever seen in my practice.

So, why couldn’t I have simply skipped all the phone calls and gone with my initial evaluation? After all, it appears that I was correct, wasn’t I? Yes, but a possibility certainly existed that I was wrong, and the risk that posed to Amanda, her family, animals in her environment and others was scary. If I had concluded that Amanda was not the perpetrator and was wrong, she would have been free to act out on other animals. In addition, this behavior was so cruel that it would have been a very small step for her to act out on humans, including younger or weaker siblings or playmates. She would have been a risk to everyone she came into contact with.

On the other hand, if I concluded that Amanda did in fact commit this act, she would have been removed from the home. She had lived in this stable, loving home for most of her life, and if my conclusions were wrong, she would have been unfairly uprooted, stigmatized and very difficult to place in the foster care system. The progress she had made might quickly have been undone, and my mistake could have had lifelong consequences for her. Both of these possible outcomes had serious consequences.

 

Follow-up

One year later, my conclusions seem to have been proved correct. The follow-up for DID resulted in no indication of multiple personalities, and the psychologist’s conclusions were the same as mine. Subsequent evaluations also rendered conclusions consistent with my original evaluation, and no other incidents have occurred in the family home or environs. To my knowledge, no other perpetrator has been pursued or apprehended.

This case presents four very important lessons for counselors:

1) Cover every base. Avoid the temptation to lean too heavily on any single piece of information or assessment for conclusions. Assessment processes, interviews, case material and other sources of information can provide triangulation and help confirm or disconfirm information that might be presented in a child’s file.

2) Material in case files may not be objective, and there may be other ways to see the behaviors recorded therein. Read these files with objectivity and caution.

3) Be tentative in your conclusions.

4) Follow up for certainty. If I had been wrong in this case, my recommended follow-up could literally have saved someone’s life.

 

 

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Gregory K. Moffatt is a professor of counseling and human services at Point University. A licensed professional counselor, he has more than 25 years of clinical experience treating trauma with children. Contact him at Greg.Moffatt@point.edu.

 

The connection between ADHD, speech delays, motor skill delays, sensory processing disorders and sleep issues

By Donna Mac January 16, 2015

To ensure the overall well-being of child clients with attention-deficit/hyperactivity disorder (ADHD), counselors frequently work in combination with other service providers such as speech therapists, physical therapists, occupational therapists and sleep specialists. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), many children with ADHD have also ADHD2experienced speech delays, gross motor delays and fine motor delays. In addition, many clients with ADHD showcase sensory issues or have a comorbid sensory processing disorder. Many children with ADHD seemingly also struggle to settle down at night, especially when parents are trying to get them into bed.

What is the connection between ADHD and these other deficits? If we take a look at the structural and chemical makeup of the ADHD brain, we find similarities with these other areas. First, let’s take a look at what an ADHD brain can look like:

  • There can be a smaller frontal lobe with less blood flow to it. This is where the executive functions exist: planning, organization, task initiation, task completion, time estimation, time management, self-regulation, social behavior, short-term memory, working memory, motivation, impulse control, intentionality, purposefulness and the ability to transition effectively. A smaller frontal lobe will lead to emotional immaturity.
  • The overall cerebral volume is usually smaller as well.
  • The neurotransmitter systems of dopamine and norepinephrine are affected. People with ADHD do not produce enough, retain enough or transport these neurotransmitters efficiently through the brain. MRI studies show that this inefficiency can be due to less white matter and more grey matter in the brains of clients with ADHD, which slows transportation. Dopamine is the main “focus neurotransmitter,” heavily associated with the frontal lobe and the executive functions, in addition to being the “feel good” neurotransmitter. It is also heavily linked to the limbic system, which contributes to people with ADHD reacting in a manner that is disproportionate to the event, either positively or negatively. Norepinephrine is involved in focusing on tasks a person considers to be either boring or challenging. In addition, it plays a role in sleep.
  • These clients can have a smaller caudate nucleus with less blood flow to it. The caudate is heavily innervated by dopamine neurons, and it plays an important role in learning, memory, social behavior, voluntary movement and sleep.
  • Electroencephalograms (EEGs) have shown that people with ADHD have more slow waves (theta waves) present than the general population when they are in an “awake state.” The increase in slow waves is especially pronounced during reading and listening tasks, causing people to lose focus, daydream or become drowsy.

All of this simply means that the ADHD brain is less mature and has less activity than a neurotypical brain. It is important to note that a doctor will not order an EEG or MRI either to diagnose or rule out ADHD because these findings are not indicative only of ADHD. In fact, many other issues present this way, including the following.

Speech delays: As stated earlier, the frontal lobe plays a key role in ADHD, but it also plays a role in speech production. There is a significant distinction between those with ADHD who have had speech and language delays versus the general population. It is also important to understand that children with speech and language delays typically have attention spans commiserate to where they are developmentally with language. For instance, if a 7-year-old speaks at a 4-year-old level, the child’s attention span may be that of a 4-year-old. This does not mean the child has ADHD. In addition, the child with a speech delay might find it challenging to communicate needs appropriately, so the child may begin to act out, have tantrums or melt down, much as a child with ADHD might demonstrate. Therefore, if a child has a speech and language delay, a thorough investigation needs to be conducted to determine whether the child’s “ADHD types of struggles” (of both attention and behavior) are related to the language delay, or if, in fact, the child also has ADHD.

If a child does have both ADHD and a speech delay, a physical therapist can make recommendations to the speech therapist concerning how to use specific large-body movements during speech therapy sessions. This will bring blood and glucose to the frontal lobe of the brain. This can be beneficial for speech production and will help the child with ADHD to feel more emotionally regulated.

Another speech issue connected with ADHD is speaking too quickly. This will sound almost as if the child’s speech is slurred. This can be due to the cognitive impulsivity related to ADHD. It can be addressed in a psychotherapy session or a speech session by having the child draw slow, wavy lines as the child speaks.

Motor skill delays: The ADHD brain processes slower than a neurotypical brain because of the transportation difficulties with the neurotransmitters and also because of the increase in slow wave (theta wave) movement. Interestingly enough, researchers find that about half of all children with developmental gross motor coordination disorders actually suffer from varying degrees of ADHD.

Why? Possibly because slower brain processing speed is also manifested in motor skill deficiencies. These motor delays are helped by physical therapists. However, there are other techniques used as well because there are activities that can help speed processing in the brain, such as balance-based activities. Physical therapists and occupational therapists tend to work together to incorporate balance-based activities with both motor skill delays and ADHD because the act of balancing the body actually requires the use of both hemispheres of the brain. In turn, this speeds processing, increases focus and decreases impulsivity.

Other extracurricular activities such as gymnastics, yoga and martial arts involve balance and practicing controlled movement, which are crucial for both ADHD and motor skill deficiencies. Some children with ADHD will have difficulty with fine motor issues such as buttoning clothing or tying shoes, and occupational therapists can help with those concerns as well.ADHD1

Sensory processing disorders: Reward-deficiency syndrome is when the brain is asking for more dopamine. This can be witnessed in the hyperactive response of those with ADHD when they “sensory seek” (spinning around and around, for example) or “novelty seek” (such as hanging over a two-story banister). Dopamine also limits and selects the sensory information that arrives to the frontal lobe, which is one reason that children with ADHD show these sensory issues. In addition, there is a less developed frontal lobe in cases of ADHD. This poses a “double whammy” because both dopamine and frontal lobe issues are involved with sensory concerns as well.

An actual sensory processing disorder occurs when a person has difficulty with the way the brain senses, organizes and utilizes sensory input. This results in unexpected outcomes of movement, emotions, attention and adaptive behaviors. It is as if the brain is using unexpected information on the way in, so, naturally, the unexpected emotions and behaviors come out, which can create further stress and anxiety for the person. Some people with ADHD will have certain sensory concerns without having a full-blown sensory processing disorder, but other people will have both ADHD and a sensory processing disorder. Occupational therapists are skilled at helping children with these issues.

Sleep issues: Children with actual sleep disorders or inconsistent sleep patterns will showcase symptoms similar to ADHD such as irritability, less developed social skills, attention difficulties, memory impairment, lower academic output, increased internalizing and externalizing of problems, not complying with requests and aggression. Because of this particular symptomology, it is crucial to rule out a sleep disorder before diagnosing ADHD.

Can a person have both ADHD and difficulty sleeping? Yes, but not always. A study was published in The New York Times in which researchers focused on children with comorbid diagnoses of ADHD and a sleep disorder. A year after surgeries or treatments for the sleep disorders, only half of the children retained their ADHD diagnosis, meaning that the other half had been misdiagnosed with ADHD; it was only the sleep disorder causing their symptoms.

It’s important to note that “trouble sleeping” was once a symptom qualifier to secure an ADHD diagnosis. The symptom was removed from the DSM in 1987, but the issue can still occur with some people. Remember that the caudate nucleus and norepinephrine are involved in both ADHD and in sleep, which is one reason people may struggle to sleep some nights. Most children with ADHD tend to have difficulty settling down at night and getting into bed because of their hyperactivity and impulsivity, which can spike in the evening hours. But once in bed and calmed down, children with ADHD can usually fall asleep in a time frame that is considered “within normal limits.” Many children with ADHD tend to wake quickly and experience an accelerated start to their day.

 

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Donna Mac has worked professionally with ADHD for 15 years as a teacher, a YMCA director and currently as a licensed clinical professional counselor in a therapeutic day school. She is also the mother of twins diagnosed with ADHD at age 3. She has published a book titled Toddlers & ADHD, available on Amazon.com, BarnesandNoble.com, Balboapress.com and at her website: toddlersandadhd.com.