Tag Archives: Children & Adolescents

Children & Adolescents

One in three American kids affected by adverse childhood experiences

By Bethany Bray November 5, 2019

One-third of American children have gone through a negative experience that can have lasting implications for their physical and mental health, according to the U.S. Health Resources and Services Administration (HRSA).

Data from the agency’s most recent National Survey of Children’s Health indicates that 33% of children ages 17 and younger have gone through an adverse childhood experience (ACE) such as domestic violence or parental incarceration. Approximately 14% of children have gone through two or more ACEs, with a higher prevalence among black youths and those who live in households that are below the federal poverty level.

Among the children who took the 2018 survey, the most prevalent ACE was the divorce or separation of a parent/guardian (23.4%), followed by living in a household with someone with a drug or alcohol problem (8%), and the incarceration of a parent/guardian (7.4%).

“The new HRSA data is important because it helps us remember that all children are vulnerable to adverse experiences,” says Evette Horton, a licensed professional counselor supervisor and president of the Association for Child and Adolescent Counseling, a division of the American Counseling Association. “Our job as counselors is to assess for these adverse experiences and enhance the resilience factors that we know support children and adolescents. These include evidence-based mental health treatments, strengthening family support systems, and connecting to other resources in the community. Professional child and adolescent counselors are well-versed in promoting protective factors and stand ready to support children with any adverse experience.”

The U.S. Centers for Disease Control and Prevention defines ACEs as “all types of abuse, neglect and other potentially traumatic experiences that occur to people under the age of 18.” These experiences can range from the death of a parent to emotional or physical neglect and witnessing violence in a home or neighborhood.

Research has connected ACEs to health problems later in life such as mental illness, heart disease, addictive disorders, cancers and diabetes, and risky behaviors such as illegal drug use, unintended pregnancy and suicide attempts.

HRSA collects information on a range of children’s health-related topics from households across the U.S. for its annual survey; the most recent survey includes data from more than 30,500 children.

HRSA cannot directly compare the 2018 rate of ACEs to data from previous surveys because the language in a question asking about ACEs was changed last year. However, when excluding data for the question that was altered (regarding financial hardship), there was not a significant change in the number of ACEs between the 2016, 2017 and 2018 surveys.

 

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More from HRSA on the National Survey of Children’s Health: hrsa.gov/about/news/press-releases/hrsa-data-national-survey-children-health

 

Fact sheet on the 2018 survey: mchb.hrsa.gov/sites/default/files/mchb/Data/NSCH/NSCH-2018-factsheet.pdf

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Related reading, from Counseling Today:

Coming to grips with childhood adversity

The toll of childhood trauma

Informed by trauma

Counseling babies

Standing in the shadow of addiction

What’s left unsaid” (on child sexual abuse)

Interventions for attachment and traumatic stress issues in young children

Touched by trauma

 

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Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Using reality therapy to help military families

By Nicole M. Arcuri Sanders June 14, 2019

Military children are the “Children of the world, blown to all corners of the world. [They] bloom anywhere.” Just like dandelions, military children never know where they will go and where they will grow.

Diane Townsend Davis is credited with creating the dandelion motto for military children. Understanding this motto is imperative for any counselor who wishes to work with military children, but especially for school counselors. The Department of Defense Dependents Education (DoDDE) estimates that 80% of military children (approximately 1.2 million) attend public schools.

Counselors who work with military children must understand the unique stressors that these children face, but counselors also must be prepared to help meet these children’s needs in a short amount of time because their families move often. To avoid having these children slip through the cracks, school counselors must be knowledgeable about rapport-building strategies with this population and meet their needs in a realistic time frame.

 

Reality therapy

Working with clients from their worldview is not a new concept for counselors. This is particularly important when working with a population connected to the military because these clients’ perspectives differ drastically from those of the civilian population. Being knowledgeable about the unique needs of the military culture is a necessity for effective counseling work. For instance, often as military children begin to find their niche in a school, their families will receive orders for relocation. Military families relocate 2.4 times more often than do civilian families (on average, military families relocate every two to three years).

Reality therapy offers this population an honest evaluation of their current choices and behaviors to determine if change is needed to obtain their desired outcomes. This modality offers something that is very important to consider for this population —an emphasis on what aspects of life the client has control over.

As noted, military children move often and therefore tend to be the new kid in school quite frequently. But these children are not like most other new children in school. These children:

  • Have parents who are willing to sacrifice their lives for the well-being of the nation and to safeguard its people
  • Have parents who often leave for extended periods of time to either train for combat-related situations or as part of combat-related missions
  • Know that a great deal of risk is associated with their parents’ jobs
  • Don’t always know whether their mom or dad made it back safely from work
  • Can go for months without being able to see their parent(s)

In an age of social media, these children may at times be able to connect with their parents, but they also might see or hear reports of attacks on the news. When a member of a military unit is killed in action, all communication is cut off at their deployment station to ensure that the family of the service member is notified prior to receiving any other communication. When military children are unable to connect with their parent, the fear of the death being their father or mother is very real. All of the above noted aspects are the reality for military children, and all of these aspects are out of their realm of control.

Reality therapy offers these clients the opportunity to form a relationship with their counselor based on understanding and nonjudgment. Clients have a voice when working with counselors who use reality therapy. The clients become empowered by being afforded the idea of having control over their behaviors and actions.

A basic tenant of reality therapy is aiding clients in having their basic needs met. Creating a safe place in which clients do not feel judged but do feel empowered is therapeutic in itself.

Reality therapy is founded on the idea that everyone is seeking to fulfill five basic needs:

1) Love and belonging

2) Power or sense of worth

3) Freedom or independence

4) Fun or a sense of pleasure

5) Survival (which is based on knowing that one’s basic needs are being met)

When one of these needs is not being met, mental health issues can arise.

For clients connected to the military, feeling loved and belonging might look different than it does for other clients. Because these clients are frequently separated from loved ones and move often, meeting their need to feel loved and belong can be challenging. Reality therapy provides these clients with the understanding that they cannot change or control others. So, the practical approach will be to solve problems through their ability to control themselves and their own behaviors and thus make choices that support their needs and desired goals.

Within the military, very little power is offered to the family or the service member. Ultimately, the family and service member follow orders from a multitude of levels within the Department of Defense (DOD). Yet each military-connected member can feel a sense of accomplishment through actions they choose to control. For instance, helping clients make a list of goals that they want to accomplish while living somewhere (i.e., making the best out of each duty station) can be empowering to them.

Gaining knowledge of a new area through exploration can also be empowering. Helping clients identify their interests (and what makes them unique) can further support their independence and wellness. Fun can also be part of that experience.

Of course, with each transition that military-connected clients face, their survival needs will be tested. For instance, they may need to realign their thoughts regarding shelter (housing). Yet helping these clients differentiate what is out of their control and what is in their control can aide them in pursuing actions that support the desired outcomes that are within their control. Clients may still be angry, confused or saddened by aspects that are outside of their control. But counselors can help clients see that rather than blaming others or relying on these aspects as an excuse, they can focus on and take ownership of their present time and actions.

Reality therapy sessions are structured around the WDEP system — the client’s wants, doing, evaluation and planning. The counselor meets the client in the here and now and explores what the client wants. This realistic exploration of attainment notes what is in the client’s control and what is not. Clients then share what they are doing to help themselves achieve their wants. Next, the counselor helps clients evaluate whether what they are doing is supportive of or detrimental to their goals. Then, together, the counselor and client plan ways to change detrimental behaviors and fine-tune supportive behaviors to allow for the client to obtain his or her wants.

As the client is faced with new areas of need, the same WDEP system can be applied. Military-connected clients are faced with many hardships fostered by their culture. But reality therapy offers this population a real chance to be resilient by adapting to change and overcoming challenges.

 

Resilience

Military child resiliency largely resembles how well the stay-behind parent is doing. If the parent is unable to cope or transition with the needs of the family when the service member is not available to assist them, then a domino effect will occur. Children will have to fulfill adult responsibilities in the absence of the service member. The parental stressors will then be placed on the children’s shoulders.

For some parents, missing a spouse may be too much for them to handle. Other parents who are left behind may not be married or may not currently be together with the service member, but they may still rely on the service member for support with the children.

When there is a lack of available support, the additional stressors put these families at risk. A 2008 report from the Military Family Research Institute found studies to support that since 9/11, when the number of deployments for service members increased, military families experienced increased rates of marital conflict, domestic violence, child neglect or maltreatment, parenting stress, anxiety and depression.

On the opposite side, when the parent left behind is able to successfully juggle the transition and continue meeting both personal and family needs, children experience less turmoil. These children are better able to continue on as normal with minimal changes to other aspects of life. However, having resources available to these parents to support them in filling roles for which the service member parent was typically responsible is imperative.

Civilian school counselors and community mental health counselors should consider that the resources that military families rely on may not be readily available. For instance, counselors should note whether additional family support is local versus distant and how long the family has called its current community home. Again, reality therapy can provide these clients with a realistic perspective of addressing their needs. Therefore, it is important for counselors to know what additional supports are available to these families.

 

School counselors

According to the National Center for Education Statistics, children across the United States spend an average of 6.64 hours a day and a 180 days per year attending public schools. As noted previously, 80% of military children attend public schools.

Public schools have a duty to be aware of the needs of military children. In its 2012 national model, the American School Counselor Association (ASCA) asserts the necessity for school counselors to understand their students’ culture in order to provide effective support for students’ academic, career and personal/social development. ASCA further proclaims in its 2012 executive summary that school counseling programs can be effective only when a collaborative effort exists between the school counselor, parents and other educators, thus creating an environment that promotes student achievement.

School counselors who use reality therapy can support students’ academic, career and personal/social development. For each of these areas of development, the school counselor can address the student client’s wants and doing while also aiding the student in evaluating such efforts and making plans that support success. Yet without understanding the unique needs of the military lifestyle, school counselors will be unable to support these children in the schools or locate appropriate community resources to provide support outside of school. Therefore, when assessing the student client’s wants, a realistic perspective of the stakeholders involved will aid in developing goals that the student client has control over.

 

Community counselors

The same notion of understanding the unique needs of military children and military families is true for civilian community counselors. According to the ACA Code of Ethics, the primary responsibility of a counselor is to respect the dignity and promote the welfare of clients (Standard A.1.a.). This notion alone requires counselors to take the specific needs of their clients into consideration.

To best do this, counselors should not impose their own values on clients (A.4.b.) but instead should honor the diversity of clients and their uniqueness within their social and cultural contexts. Reality therapy promotes this understanding by developing a therapeutic relationship that embraces the client’s worldview and operates from that perspective in developing realistic goals.

 

Realistic intervention

As military children, family members and service members are blown to all corners of the world, professional counselors should be asking themselves a question: “How can we best serve these clients so that they can bloom?”

All counselors should have the same mission when working with this population — namely, devising goals that are realistic and attainable for these clients. Counselors must make themselves knowledgeable of the specific resources that are available to this population to promote therapeutic growth rather than presenting yet another barrier that these clients must face. There are many resources available exclusively to service members, veterans and their families of which civilian counselors may not be aware. When working with military families, it is imperative that counselors do their homework regarding these resources before leading clients blindly with an analysis of client control in establishing wants or goals.

Toward the end of this article, I will share a number of resources that are available to assist military families living off base. But let’s next consider what civilian counselors can do.

For starters, civilian counselors will want to build rapport with the military-connected client while being mindful of their cultural worldview (just as they would with any other client). This will require the counselor to be knowledgeable about the military population and the client’s role within the military family. As noted earlier, this is a unique culture, and being able to understand this lens of perception will be helpful when clients are processing and trying to navigate scenarios for realistic solutions or coming to terms with aspects that may be troublesome (again, following the tenets of reality therapy).

Second, whether working with the service member, the child or the stay-behind parent, consider infusing into the treatment plan the power of resiliency. Due to their lifestyle, military-connected clients are typically used to a great deal of adjustment in various aspects of their lives on a regular basis. Helping clients build off of their past successes to navigate new challenges can be empowering. Reality therapy supports counselors in evaluating with clients what is working and what is not.

In 2008, the Military Family Research Institute found that the following stressors were considered normative for military children but not for civilian children:

1) Regular, and at times lengthy, separations from parents

2) Lengthy parental work hours

3) Permanent changes of station

4) Deployments for multiple and various purposes

5) Exposure to combat-related activities and equipment, including training

Just because the stressors are considered normal for the population, the events and circumstances experienced are not to be inferred as easy for military children to manage. Just like with any stressor for any client, the more sudden, serious, ambiguous or traumatic the loss, the more difficult the stress will be to manage. Many of these same stressors are applicable both to the parent who is left behind and to the service member.

It is common for military couples to experience marital distress due to a multitude of these stressors. Commonly seen mental health issues in the military population for the service member and veteran include mood disorders, trauma/posttraumatic stress disorder, sexual assault, suicide, addiction, adjustment issues and relationship concerns. Commonly seen mental health issues among military spouses and children include mood disorders, trauma, adjustment issues and relationship concerns.

To explore an issue that may plague any member of a military family, we will focus on working with a military-connected client who is experiencing relationship issues. Guiding these clients in exploring how to communicate with their families despite the physical distance between them and how to involve family members in their life even from afar can help with feelings of detachment. Reality therapy offers clients the ability to come to terms with aspects of their lives that are in their control as well as outside of their control.

Finding ways to help clients embrace the family dynamic even when changes occur can help sustain the idea of their family system. Highlighting previous resiliency efforts to help clients explore this new change, come to accept it, and adapt how they now fit into their family system can reinforce the idea of maintaining relationships. WDEP analysis for each consideration posed by clients offers not only a realistic evaluation of their current circumstance, but also celebrates their small victories and offers opportunities to modify aspects that are not supporting their desired wants.

Navigating the change within the family while assessing client strengths and processing their feelings regarding the change (as well as the realistic desires of the client, while still being mindful of the military lifestyle) can aid the client in managing more healthy relationships. This can be extended to other relationships outside of the family as well.

The idea of resiliency and understanding military culture is at the core of helping these clients. Reality therapy offers counselors the ability to seamlessly integrate into each session regardless of how much time they ultimately have with these clients.

 

Resources for all

To provide additional effective supports when working with children and families connected to the military, it is necessary to know where to turn. These additional supports are very important because these clients move frequently and are often far from family and friends who might normally offer assistance. And counselors cannot do it all by themselves.

The resources mentioned below are only a few of the many available to military families. However, they are a great place to start, whether you counsel military-connected children and their families in the school setting or in the community.

American Red Cross: Offers support with emergency communications with service member while deployed, financial assistance, information and referral services, deployment services, and Reunification Workshops.

Exceptional Family Member Program (EFMP): Program is intended to support service member dependents who have ongoing medical, mental health or special education needs (on both spectrums — gifted as well as challenges). To enroll, service members should complete and submit 1) DD Form 2792, the Family Member Medical Summary or 2) DD Form 2792-1, the Family Member Special Education/Early Intervention Summary to their installation EFMP office.

MIC3 (mic3.net/): This is the official website of the Military Interstate Children’s Compact Commission. The goal of the interstate compact is to replace the widely varying policies affecting transitioning military students with a consistent policy in every school district and in every state that chooses to join.

Military Child Education Coalition: The coalitions three goals are the following:

1) Military-connected children’s academic, social and emotional needs are recognized, supported and appropriate responses provided.

2) Parents, and other supporting adults, are empowered with the knowledge to ensure military-connected children are college, workforce and life ready.

3) A strong community of partners is committed to support an environment where military-connected children thrive.

Military family life counselors: Intention is to support service members, their families and survivors with nonmedical counseling worldwide. Counselors provide face-to-face counseling services, briefings and presentations to the military community both on and off the installation.

Military and Government Counseling Association (MGCA): MGCA is a division of the American Counseling Association with the mission of servicing those who serve. Its website says, “The purpose of MGCA is to encourage and deliver meaningful guidance, counseling, and educational programs to all members of the Armed Services, their family members, and civilian employees of Local, State and Federal Governmental Agencies. … Develop and promote the highest standards of professional conduct among counselors and educators working with Armed Services personnel and veterans. Establish, promote, and maintain improved communication with the nonmilitary community; and conduct and foster programs to enhance individual human development and increase recognition of humanistic values and goals within State and Federal Agencies.” MGCA publishes the peer-reviewed Journal of Military and Government Counseling. The journal publishes articles on all aspects of practice, theory, research and professionalism related to counseling and education in military and government settings.

Military Kids Connect: Military Kids Connect is an online community for military children (ages 6-17) that provides access to age-appropriate resources to support children dealing with the unique psychological challenges of military life.

Military OneSource: Military OneSource offers a range of individualized consultations, coaching and counseling services for many aspects of military life. Services include confidential nonmedical counseling, spouse education and career opportunities, document translation, financial and tax consultation, special needs, spouse relocation and transition, and education.

U.S. Department of Defense Education Activity school liaison officers: The purpose of this position is to serve as the primary point of contact for school-related matters; represent, inform and assist commands; assist military families with school issues (to include providing parents with the tools they need to overcome obstacles to education that stem from the military lifestyle); coordinate with local school systems; and forge partnerships between the military and schools.

Many of the resources available to military service members and their dependents (spouse and children) are free of charge. Noting this may be the difference in whether military families seek these resources out.

 

Summary

I hope this article has provided some insights regarding the needs of military children and their families. In order to provide effective school and community resources for this population, it is important to be aware that these children are not located only on military installations; they are also on public school campuses and in civilian communities. To safeguard the well-being of these children and their families, it is also imperative to understand the uniqueness of military culture.

Currently, there is a gap in services for military families living in the civilian realm. The purpose of this article is to build confidence among civilian school counselors and community counselors by suggesting realistic resources that will help them to better support this population. You never know if a dandelion will blow into your community and need assistance to bloom.

 

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Nicole M. Arcuri Sanders is a licensed professional counselor and core faculty at Capella University within the School of Counseling and Human Services. Clinically, she engages in practice with the military-connected population. Within this specific area of focus, she has also completed research, published, and presented at local, regional and national conferences to advocate for effective clinical services to meet this population’s needs. She has previously worked as a DoDEA district military liaison counselor, substance awareness counselor, school counselor, psychiatric assessment counselor, anti-bullying specialist and teacher. Contact her at Nicole.ArcuriSanders@capella.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Interventions for attachment and traumatic stress issues in young children

By Cirecie A. West-Olatunji, Jeff D. Wolfgang and Kimberly N. Frazier April 2, 2019

Although mental health professionals acknowledge that clinical issues often look different in young children, treatment practices continue to rely heavily on adult literature. These mostly miniaturized forms of adult treatment are often scaled down using more basic language and vocabulary, but they still depend on discovering ways to encourage the verbal communication of children. Furthermore, major deficiencies exist in the mental health care delivery system for children. General neglect and fragmentation of services create obstacles to effective service provision for this population.

Over the past decade, scholars have begun exploring early childhood development and effective counseling interventions, the role of traumatic stress in the presentation of emotional and behavioral symptoms, and the prevalence of attachment issues for young children. In this article, we aim to provide a brief overview of these key advances in what we have named “pediatric counseling.” We also offer 10 evidence-based counseling interventions that stem from our work with young children over several decades.

Early childhood development and counseling

Children are not miniature adults, meaning a paradigm shift and specialized skills approach are required to help them most effectively. Children also go through rapid developmental stages, strengthening the argument that therapy with children should be vastly different from therapy with adults. Thus, professional counselors and other mental health professionals must consider various concepts, issues, techniques and interventions that are cognitively, emotionally, psychologically and developmentally appropriate for children.

During early childhood, defined as birth to age 5, rapid development of gross motor skills (running, climbing, throwing) occurs. Fine motor skills (drawing, writing, manipulating small objects) are slower to develop at this stage, but children should be able to copy letters and small words sometime during the latter half of early childhood. Cognitive development at this stage is based primarily on preoperational thinking. Hence, children in this stage rely heavily on what they see. They can now recall past events and anticipate future experiences that may be similar. At this stage of development, children are very egocentric, commonly overestimate their abilities (e.g., thinking they can carry things that are too heavy for them), and gain increased control of their impulses.

Play is extremely important to social development during early childhood. At about 3 or 4 years old, children engage in associative play in which they learn how to share and interact with one another. During associative play, there are no clear goals for the play and the roles of those engaging in play are not assigned. At about age 5, children begin to create games, form groups and take turns. Children are expanding their vocabularies at this stage, but the words and phrases used to express feelings and emotions remain limited. Because of their limited emotional vocabulary at this stage, children are more prone to act out their emotions behaviorally.

Deficiencies in service delivery:
Some of the major deficiencies in the mental health care delivery system for children include:

  • How children are categorized (i.e., poor conceptualization of children within their ecological context, including culturally marginalized children being overrepresented in the most severe clinical categories)
  • Environmental factors (such as racism and poverty)
  • Lack of empirical data
  • Fragmentation of services

First, children are typically placed in categories of clinical, subclinical and at risk, and they are often in need of services such as remediation and prevention. However, they are largely neglected within the system. This is partly due to clinicians’ lack of training to provide developmentally appropriate clinical care for this age group. Lack of adequate funding and poor communication between providers (such as pediatricians, child care workers, parents/caregivers, social services personnel and professional counselors) are also factors.

Second, some environmental factors associated with higher rates of mental health problems include poverty, racism, abuse and familial problems. Systemic oppression is also linked to both behavioral and affective problems. However, insufficient research has been conducted with young children to provide adequate information about how these environmental factors affect them. 

Third, there is a lack of empirical data on effective treatment for young children. Although the literature is replete with community agency programs and hospital-affiliated programs designed for young children and their families, there is insufficient support for the effectiveness of the treatments and interventions provided.

Finally, there is fragmentation of the services that exist for this population. Mental health services for young children should be initialized by a social service agency or primary care physician. However, this rarely happens. Even when it does, it is unlikely that these professionals have included or interacted with counselors. Thus, many children slip through the cracks and remain unidentified until a crisis arises, meaning they are most likely to receive psychological first aid via psychiatric services.

Counselor training: Experts stress the need for counselor trainees to acquire foundational skills that serve as underpinnings for effective counseling of this population. The major challenge within the discipline of counseling is how to transform these base-level skills into effective techniques and interventions for young clients. Many beginning counselors feel ill-prepared and are often frustrated when they encounter child clients — and preschool-age children in particular. Most counselors begin their training by practicing their counseling skills on classmates and never encounter younger client populations until they are out in
the field. 

Traumatic stress issues

Researchers have suggested that symptoms of traumatic stress in early childhood include interrupted attachment displays of distress such as inconsolable crying, disorientation, diminished interest, aggression, withdrawing from peers, and thoughts or feelings that disrupt normal activities. Traumatic stress, a condition caused by pervasive, systemic external forces, can result in physiological, psychological and behavioral symptoms that negatively affect everyday functioning.

Symptoms of traumatic stress can include hyperarousal or hypoarousal, avoidance and re-experiencing. Hyperarousal in early childhood is often observed through displays of inconsolable crying, flailing about, arching the back and biting. Hypoarousal involves emotional numbing that may be observed as a child who sleeps excessively, displays a dazed expression or averts his or her eyes. Avoidance is characterized by withdrawal, which is often demonstrated as displaying less affection, consistently looking away or avoiding facial contact. Other observable features of avoidance include a fear of being separated from caregivers, refusal to follow directions, disorientation and extreme sadness.

Re-experiencing is often the most subtle of the three symptoms, but it can be observed through the presence of rigid and repetitive patterns. These patterns can include common play leading to outbursts or withdrawal if the pattern is changed or interrupted. The play or reenactments have a noticeable anxious quality to them, or the child appears to space out when engaged in these patterns. One of the most consistent observations of re-experiencing is the presence of nightmares.

Neurological responses to traumatic stress include:

  • Increased levels of adrenaline (activation of the sympathetic nervous system)
  • Decreased levels of cortisol and serotonin (a reduced ability to moderate the sympathetic nervous system or emotional reactivity)
  • Increased levels of endogenous opioids (which result in pain reduction, emotional blunting and memory impairment)

In addition, chronic stress can interrupt cognitive functions such as planning, working memory and mental flexibility. Hence, it is important to systematically assess how children use relationships, interact with others and interact with their environment. Furthermore, when traumatic stressors deplete the coping resources of caregivers, they can become neglectful or show signs of chronic danger, leading to the potential disruption of the attachment system for young children.

Attachment issues

Attachment research describes children’s behaviors along a wellness spectrum from secure attachment (most well) to insecure attachment (where children are at highest risk). With secure attachments, caregivers display relaxed, warm and positive interactions involving some form of direct expression of feelings or desires and the ability to negotiate conflict or disagreement. In this manner, caregivers are encouraging, sensitive, consistent and responsive. With insecure attachments, the child loses confidence to varying degrees in the caregiving system, believing that the caregiver lacks responsiveness and availability during times of distress or trauma.

Securely attached children typically display the following healthy behaviors during the different phases of growth:

  • Phase I (0 to 3 months): Newborns often seek out connection (eye contact and touch) and respond to familiar smells, sights and sounds.
  • Phase II (3 to 6 months): Infants begin to orient to familiar people (preferring those who are familiar to them while avoiding those who are not familiar) and are emotionally expressive, responding to others’ emotional signals.
  • Phase III (6 months on): Infants become wary of strangers and actively seek out familiar caregivers. Additionally, they begin practicing verbal and nonverbal displays of happiness, sadness, anger and fear.
  • Phase IV (from the second to third year on): These young children notably gain increased abilities to negotiate with caregivers (sometimes resulting in short-lived tantrums), are better able to coordinate goals with others (showing adaptable and responsive goals), display increasingly empathic responses to others, and progressively develop greater walking and complex verbal communication skills.

Insecure attachments styles are divided into three categories: avoidant, resistant and disorganized-disoriented. Avoidant attachment styles often can be associated with caregivers who minimize the perceptions of young children, are emotionally unavailable, and assign care of the child to others. This results in young children becoming indifferent to the presence of the caregiver, displaying detached/neutral responses to others, and minimizing opportunities for interaction with others.

Resistant attachment styles are associated with caregivers who resist distress (showing avoidance verbally or physically) and often wait for the child to get highly upset before attempting to sooth. This conditions young children to maximize distress, to resist or display difficultly in being soothed, and to under-regulate their emotions (e.g., responding dramatically to change and acting out dramatically when expectations are not met). Additionally, these children readily perceive experiences as threatening, get frustrated easily, and often approach life anxiously or as if helpless. These children initiate their interactions with others through their distress.

The third and most unhealthy attachment style is disorganized-disoriented. It is associated with caregivers who are often confrontational, helpless, frightened or disengaged (avoidant). These caregivers often passively place children at risk due to the caregivers’ lack of involvement or preventive parenting skills. Their children respond by attempting to adapt to the caregivers’ emotional needs — either caretaking or avoiding. These adaptive behaviors are often observed as consistent displays of confusion, hostility, freezing responses or caregiving responses (e.g., reassuring, pleasing, cheering up).

Counselors’ role: As counselors, we are uniquely trained to meet the needs of young children because of our emphasis on human development, prevention, ecosystems and wellness. Counselors can use three main restorative skills to intervene with young children experiencing attachment issues related to traumatic stress. We can:

  • Set up a safe and warm environment in our clinical settings
  • Display trust through culturally sensitive gestures, tone of voice and facial expressions
  • Nurture a nonjudgmental understanding of young clients while focusing on exploration, empowerment and acceptance

By engaging in these three practices, professional counselors should be able to aid young children in working through a variety of social, emotional, behavioral and learning challenges. Counselors can foster warmth and vitality by employing mutuality and relational socio-dramatic play experiences. Additionally, counselors can create mediated learning so that young children can develop the ability to self-define, contextualize and transform their reality into healthy developmental journeys. This gentle, nonthreatening rebalancing of the energy can create restorative opportunities.

Ten evidence-based interventions

In 2000, Cirecie A. West-Olatunji (one of the co-authors of this article) and a colleague created a program called the Children’s Crisis Unit, in partnership with a local YWCA rape crisis unit, to provide clinical services to young children in a five-county area when referred for allegations of child sexual abuse. Over a four-year period, the Children’s Crisis Unit provided assessment and intervention for children and provided consultation to clinicians, law enforcement, medical professionals and legal professionals, both locally and nationally. During this time, training was provided for counseling, psychology and social work graduate students who learned how to work specifically with clients from birth to age 5.

The following techniques were used systematically with hundreds of clients. Although these interventions may be similar to those used with nonsymptomatic children, in working with young children, there are several unique features, including:

  • Assessment for degree of severity
  • Remediation
  • Involvement of the caregiver
  • Bookmarking for interventions at later developmental periods

1) Popsicle sticks: This intervention can be introduced in the first session with the primary caregiver and the child. One of the appealing things about the use of Popsicle sticks is that they are very inexpensive, meaning nearly any family can afford them. Counselors can use nontoxic crayons or markers and other craft tools such as glitter, buttons, yarn and nontoxic glue. Counselors direct the caregiver-child dyad to use the Popsicle sticks to create individual members of their family as dolls. This activity can be continued at home between sessions. This intervention facilitates bonding and trust, decreases anxiety, is client-centered and culturally appropriate, and allows children to tell their story.

2) Feeling faces: This activity provides easy access for the counselor because various versions can be downloaded from the internet. Use of the feeling faces allows children to identify with other children and their facial expressions. In the exercise, the counselor directs the child to select those faces to which he or she is drawn to determine thematic links between the selected faces. The counselor then hypothesizes and contextualizes the presenting problem. This activity is useful in remediating flattened affect, with the counselor directing the child to mimic faces that match a range of emotions.

3) Storytelling: Narrative activities allow children to tell stories of their own choosing or give a particular recounting as directed by the counselor. Storytelling also allows the caregiver to recount or read the child a story that represents some resolution to the problem. Additionally, this activity permits the counselor to a) read the child a story representing some resolution to the problem and then engage in dialogue about feelings or b) collect pre- and post-observational data regarding the child’s responses.

4) Puppets: This intervention is helpful in allowing children to use dramatic play to express their feelings, recount a story or “restory” prior negative events. It can be particularly useful when the caregiver is actively involved in the puppet intervention. Puppets can be of the caregivers’ own making or ones that are available in the clinical room. Smaller and isomorphic puppets work better with infants and toddlers, whereas 3- and 4-year-old children are more likely to respond to animal-shaped and larger puppets.

5) Anatomically and culturally correct figurines: These figurines can be useful in cases of physical and sexual abuse because children are more likely to provide an accurate accounting when directed to engage in dramatic play. This intervention allows children to reenact situations that they have experienced. Additionally, it offers opportunities for children to point to parts of the body on the figurines as well as on themselves. This activity can provide the counselor with an assessment of the child’s developmentally appropriate knowledge about sexuality.

6) Dollhouse: This intervention offers a physical example of the home that can be used to explain what happens in the home from the child’s perspective. Use of a dollhouse can aid in accessing the child’s memories more easily based on familiarity with household items rather than starting from scratch. This activity allows counselors to be either:

  • Directive with the child, using prompts such as, “Tell me what happens in this room” (while pointing to a specific room in the dollhouse)
  • Nondirective with the child, permitting the child to have free-flowing play with the items in the dollhouse (while making observational notes)

7) Play dough (modeling clay): Modeling clay provides a kinesthetic, moldable medium that children can use to contextualize and express feelings involving sensory experiences. This intervention permits children to create representations of their family members by providing definition to body parts and facial expressions, and thus connecting emotions, experiences and people to the critical event. Play dough activities allow counselors to direct children to mold important people (both family members and nonfamily members) in their lives.

8) Freehand drawing: This activity offers children the opportunity to creatively express what is happening for them in the moment. Tools for this activity are based on the child’s developmental level and might include crayons, markers, pens, pencils or chalk, depending on the child’s age and motor skills. Counselors can use this activity to promote comfort, connection, nurturance and fun for children.

9) Kinetic family/human figure drawing: Kinetic family drawing is a more directive technique that allows children to articulate how they see themselves in relation to other family members. This activity allows for dialogue between the parent and child in terms of perspectives of the family. The counselor offers paper and drawing instruments and directs the child to draw a picture of her or his family. (Note: Try to avoid stick figures, depending on the age of the child.)

10) In vivo parent-child observation and feedback: This intervention permits the counselor to assume an observer role as the parent and child interact. It can be either directive or nondirective. This activity allows for a real-time view of the interaction quality between the parent and child, providing insight into parenting style and skills as well as attachment issues. In vivo observations afford counselors the opportunity to prepare the clinical room with play materials and direct the parent to engage with the child (or, in a nondirective way, allow the parent and child to interact without instructions). Thus, the counselor can step back to observe (either in the clinical room or in an adjoining room with a one-way mirror). If the counselor is in the room, she or he can provide instant feedback and redirection, if necessary.

It should be noted that when working with preverbal children, counselors should rely on nonverbals such as body language, facial expressions, physiological responses and the child’s attention and focus. Also, be aware that children’s comprehension develops earlier than their language abilities. It is important to remember that children understand more than they can communicate.

Extending our reach

The counseling profession is poised to serve as a leading provider of much-needed services to young children. Our focus on prevention, environmental context, development and wellness makes us uniquely trained to assess, intervene with and investigate clinical issues in early childhood. The benefits for us as a profession are numerous and extensive.

First, by incorporating a focus on young children, we can increase our role definition by providing psychological consultation to children, parents, and child care providers in day care centers (such as Head Start) and preschools. Second, we move from the implicit to the explicit. Many practicing counselors are already working with young children in their agencies, schools and private practices. However, without counselor educators and policymakers explicating guidelines for practice, the profession lacks a systematic response to ensure application of evidence-based interventions. Third, we can expand our involvement in addressing the needs of this clinical population by securing grants from federal agencies and private foundations; attending think tanks and conventions where other health professionals are gathering to discuss the needs of young children; and advocating for increased coordination of service providers across all service delivery platforms and agencies. Finally, we can advocate for ourselves by becoming more visible within the larger health care community.

Recommendations: Existing courses in counselor education need to incorporate a paradigm that includes training specifically geared toward clinical populations from birth to age 5. The major challenge within this discipline is how to transform base-level skills into effective techniques and interventions for young clients.

School counselors especially need to have specialized skills and training so they are equipped with tools that acknowledge characteristics and cultural nuances that are specific to child populations. Allowing graduate students to become familiar with the pediatric population early in their training begins the process of conceptualizing young children in the context of a holistic, strength-based and culture-centered approach.

Some professionals have offered a solution to this dilemma by suggesting a framework that incorporates exposure to a variety of populations or the use of various subspecialties. In such a framework, counselor educators systematically incorporate broad content knowledge of specialized populations that is applied throughout the curriculum. Family courses could focus on the specific issues that pediatric members of the family system face and how these issues affect the entire family’s functioning. In addition, family courses could focus on interventions geared toward young children that incorporate the entire family, hence aiding the family to function more effectively. Counseling courses on theory and technique might add discussions on how to incorporate young child development and issues into concepts and interventions that are specific to various counseling theories.

Finally, to further develop our understanding of what practicing counselors actually do when working with young children, it is important to perform additional counseling research. One way of advancing our knowledge in this area might be the use of a Delphi study. This systematic approach, which would gather a panel of experts through a nominations process, could be used to generate ideas, gain consensus and identify opinions of a wide range of counseling professionals without face-to-face interaction. This method could provide a means of bridging research and practice to reach a common understanding of what steps can be taken to explore our conceptualization and assessment of and intervention with young children.

In sum, counselors have the ideal training to work closely with young clients and to provide culturally appropriate interventions to address the unique needs of this client population. Use of developmentally informed and ecosystemic frameworks will allow counselors to be accurate in their conceptualization and treatment of young children.

 

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Cirecie A. West-Olatunji serves as associate professor in counseling at Xavier University of Louisiana (XULA) and as director of the XULA Center for Traumatic Stress Research. She is a past president of the American Counseling Association and the Association for Multicultural Counseling and Development (AMCD). Internationally, she has provided consultation and training in southern Africa, the Pacific Rim and Europe. Contact her at colatunj@xula.edu.

Jeff D. Wolfgang is an assistant professor in the Department of Counseling in the College of Education at North Carolina A&T State University. His research focuses on multigenerational effects of trauma on young children and their families. Contact him at jdwolfgang@ncat.edu.

Kimberly N. Frazier is an associate professor in the Department of Clinical Rehabilitation and Counseling at the Louisiana State University Health Sciences Center-New Orleans. Her research focuses on counseling pediatric populations, cultured-centered counseling interventions and training, systemic oppression and trauma. She is a past president of AMCD and has served as an ACA Governing Council representative. Contact her at kfraz1@lsuhsc.edu.

 

Letters to the editor: ct@counseling.org

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

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Parent-child interaction therapy for ADHD and anxiety disorders

By Donna Mac March 6, 2019

When one hears the term “parent-child interaction therapy” (PCIT), it might be assumed the therapy’s purpose is solely for that specific use — i.e., for parents to use with their children. However, this couldn’t be further from the truth. In fact, PCIT can be used in therapy sessions, then the therapist can teach the child’s teacher how to use PCIT in the school environment and, of course, the therapist can teach parents how to use these skills at home and in community settings, all in an effort to coordinate and synchronize treatment across settings.

Sheila M. Eyberg developed PCIT in the 1970s out of the University of Florida. It was built from multiple theories of child development, including attachment, parenting styles and social learning. In the past, PCIT was intended mostly for children 2 to 7 years old with disruptive emotional disorders and behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. The purpose of PCIT was to work on rapport building and to enhance the relationship between the child and parent, for the child to develop more intrinsic motivation to comply and for the parent to develop more positive feelings toward the child — a cycle that can then be positively repetitive.

In addition to disruptive disorders, PCIT also seems to help children with anxiety disorders. In particular, there is research demonstrating its efficacy with the anxiety disorder of selective mutism. Therefore, clinicians have also begun using it for social anxiety disorder, social phobia, school phobia and agoraphobia. In school and community settings, PCIT is used as an antecedent intervention that helps shape the environment to create an emotionally safe space for these types of anxiety disorders to be more effectively managed. (It should also be noted that PCIT can be used to treat ADHD and anxiety beyond age 7 with simple modifications.)

The goal of this therapy is to produce more prosocial behaviors, regardless of the diagnosis. For example, with anxiety disorders that specifically manifest as a fear of being around people or communicating with others, the goal is for the child to be less inhibited and avoidant. The child’s symptoms might include struggling to leave the home, averting eye contact, displaying a shrinking body posture and having frozen reactions, both in terms of a lack of verbal response and a lack of body movement (think of a “deer in the headlights” appearance). The goal in such cases is to help these children manage their symptoms so they can present in a socially expected manner.

On the other hand, children with ADHD can present as too disinhibited, demonstrating hyperactive, impulsive, incessant and intrusive behaviors, so the goal is to adjust those behaviors to be more inhibited.

Subsequently, the PCIT goal for both of these populations is to produce more desired social behaviors, which will lead to better social outcomes, thus perpetuating the cycle in a positive manner. When children receive positive social feedback, they are likely to keep using these skills in an effort to continue engaging in positive interactions.

Addressing self-esteem

PCIT is a relationship-enhancing therapeutic technique. The concepts from this therapy that I use with children who have either ADHD or avoidant anxiety disorders revolve around Eyberg’s child-directed interaction (CDI) and PRIDE skills. CDI and PRIDE go hand in hand and, when combined, have been shown to build rapport with the other person and build confidence and self-esteem within the child (in an effort to manage both disruptive and anxious-avoidant behaviors). If a child feels comfortable with a certain relationship, that child may feel more valued, worthy and confident and have stronger self-esteem. As a result, the child will be less anxious, better able to manage disruptive impulses and more likely to use expected social skills.

Children with ADHD often struggle with their self-esteem because of the amount of negative feedback they tend to receive on a daily (or more frequent) basis: “Don’t touch everything in this store.” “Stop asking me if we can go to the pool.” “Leave your sister alone.” “Why can’t you just behave?” Yet if a child receives positive feedback versus corrective feedback in an approximate ratio of 4-to-1, the child will be more likely to comply with the directive to “stop asking that question,” to “leave your sister alone,” etc.

Children with the avoidant types of anxiety disorders also struggle with self-esteem because of the negative judgments they assume and perceive that others are making about them. When these children receive praise, it helps them feel less anxious. In turn, when their brains are stabilized, they are more able to use their actual abstract counseling strategies (such as cognitive behavior therapy, or CBT) on themselves to manage their anxiety and actually “leave the house,” “maintain eye contact,” “use complete sentences” (rather than one-word answers), etc.

In therapy, PCIT can be used as a stand-alone treatment, but I recommend combining it with other therapeutic treatments such as operant conditioning, exposure therapy and CBT. Of course, the use of CBT will depend on the age of the child and whether his or her brain is developed enough to process abstract counseling strategies. Children don’t usually possess this ability until age 7 or 8. It should be noted that use of these treatment techniques (alone or in combination) does not guarantee success or an absence of symptoms.

Implementing PCIT with CDI and PRIDE

Some professionals refer to CDI as “child chooses.” Regardless of the terminology, during this portion of PCIT, no directives are to be given to the child and no questions are to be asked until CDI has been used for at least three minutes. This allows the child to feel positive about himself or herself because nobody is giving directions to correct something that the child was “doing wrong” upon entering a room or during a new transition.

When children feel positively about themselves, they are more likely to comply later down the line. Therefore, it should be noted that CDI is not a time to criticize. CDI means that the child will choose something to do without any adult direction. The adult (whether that is the counselor, the parent or the teacher) is to observe what the child does and give the child physical space if the adult’s presence seems to agitate or increase anxiety in the child. After at least three minutes of CDI, the adult uses PRIDE skills (verbal interaction from the adult) when the child seems more emotionally regulated. PRIDE is an acronym that directs the adult to offer the child labeled praise, reflection, imitation, description and excitement/enjoyment (in the adult’s voice).

As a real-life example, let’s say that “Alison” is in homeroom at school first thing in the morning. At the therapeutic school in which I work, this is where the students meet in the mornings to get any homework lists, eat healthy food, use coping skills, check in with their teachers and therapists, and practice socializing with peers appropriately. CDI is used immediately upon students’ arrival.

In this case, Alison puts her backpack on the floor upon entering the room, then goes to sit at her desk (her backpack is not where it is supposed to be, plus it is open, with its contents falling out). When Alison enters the classroom for the first time, it is time for CDI, so the teacher is not to direct her to move the backpack, at least for a few more minutes. (If your first interaction involved someone telling you to correct something, think about how you would feel.)

At her desk, Alison eats an apple, and then a peer asks Alison for a piece of paper. Alison silently gives her peer the paper, without offering any eye contact, and then gets up to throw away the apple she just finished eating. She then remembers to get her assignment notebook out of her desk. Even though Alison’s backpack is open on the floor with papers, food and more disorganized contents spilling out, the teacher doesn’t direct her to do anything until after offering Alison the full array of PRIDE skills:

  • Praise: Praise appropriate behavior. This should be specific labeled praise about what is positive. In this case, it could be any number of things: “Alison, thanks for sharing your paper with Sarah. You are so helpful” or “Thanks for throwing away that apple in the garbage. You are very responsible” or “You remembered to get out your assignment notebook. You have a great memory!” This labeled praise includes helpers to build confidence in Alison related to both her IQ and her EQ (emotional intelligence), therefore lessening her anxiety and helping her manage her impulsivity.
  • Reflect: Reflect appropriate talk. This means the adult reflects back what the child says to them. For example, when Alison is done with her assignment notebook, she asks the teacher, “When is the fire drill?” The teacher is to reflect the main concept of the question. In this case, the teacher might say, “I am glad you want to know when the fire drill is so you can be prepared. That is very responsible of you. It is at 9.” Reflection is key to letting children know you are really listening to them. And if someone is listening to them, then they feel valued, understood, worthy and accepted, lessening their anxiety and raising their self-esteem. In this case, the teacher also offered more labeled praise about Alison being prepared and responsible.
  • Imitate: Imitate appropriate social behaviors. If Alison takes out paper and colored pencils to draw as a “quiet coping” skill during the appropriate time, the teacher takes note of how to imitate this same concept down the line. “Your drawing just reminded me of something, Alison. When all of the homeroom students have arrived, we can all play that drawing game we played a few weeks ago. Would you be willing to lead the game since you really understood it last time and are such a talented artist?” This lets Alison perceive that she is worthy because she was doing something that the teacher also wants to do (artwork). This serves to lessen Alison’s anxiety. It also helps her realize that she can in fact be a leader herself, increasing her self-confidence.
  • Describe: This is the time to give behavioral descriptions. Simply describe what the child is doing, which shows the child that someone is both attending to them and giving approval of their actions. This serves to increase the child’s confidence and decrease anxiety. For example, the teacher might tell Alison, “You’re drawing a sports car with a mountain in the distance. That looks fast and powerful yet peaceful at the same time. That’s pretty impressive and creative that you’re able to capture all of that in one picture.” This description also includes more labeled praise pointing out that Alison is creative.
  • Excitement/enjoyment: Demonstrate excitement in your voice, which is key to attending skills. This strengthens the relationship with the child and allows the child to experience many positive feelings. This also increases the chances the child will comply when you give a corrective direction.

It should be noted that some people with anxiety fear receiving positive praise in front of other people. If this is the case, adjustments can be made to the treatment technique.

In Alison’s case, all of the PRIDE letters were used, and she received even more than the allotted three minutes of CDI time. Alison’s CDI time included getting to choose to eat her apple, asking her fire drill question and taking out paper to draw a picture. Once CDI and PRIDE have been used, the teacher can move to adult-directed interaction, in which the teacher can finally:

  • Ask questions: “Alison, do you have your math assignment from last night?”
  • Direct some peer interaction (such as getting the students together for the drawing game referenced earlier).
  • Give instructions (such as addressing that backpack issue): “Alison, it would help us out if you could close your backpack and put it in your locker. I would hate for anything of yours to get lost or for someone to get hurt tripping on it.” When Alison complies with that direction, the teacher can follow up with more labeled praise: “Thanks for following directions.” One caveat: Never say, “Thanks for listening.” There is a big difference between someone “listening” and someone “following directions.”

Other considerations

The CDI/PRIDE skills/adult-directed interaction combination should be used in the child’s home continuously, at play dates in others’ homes, at school and community activities and, of course, in the therapy office. PRIDE continues to be a way of communication, so it doesn’t stop when the conversation gets going.

In the therapy office, once emotional regulation has been established with the combination of CDI/PRIDE/adult-directed interaction, the counselor can move to reminding the child of the operant conditioning plan, then work on CBT skills or exposure skills to continue building strategies to manage impulsivity or anxiety.

If children’s ADHD symptoms are impairing their social and educational functioning with significant intensity, frequency and chronicity, it is also likely that a psychiatrist will prescribe a stimulant medication. ADHD is a genetically based, neurobiological disorder that affects many parts of the brain. Medication can touch parts of this, especially when it comes to dopamine and norepinephrine disruptions, but it can’t adjust everything. Even for the parts of the brain that can be medicated, medication doesn’t guarantee an absence of symptoms. That is why it is crucial to continue using therapeutic techniques as antecedent management and counseling strategies to help children function in their different environments.

In terms of anxiety, for those suffering impairment in their social and educational settings on an intense, frequent and chronic level, the first line of medication will likely be a selective serotonin reuptake inhibitor (SSRI). This is because the main area of the brain affected is serotonin (in addition to anxiety affecting norepinephrine, glutamate and the limbic system structures of the hippocampus, hypothalamus and amygdala). Again, however, an SSRI will not guarantee an absence of symptoms, which is why therapeutic techniques, exposures and counseling strategies remain key.

 

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For more examples of how the attending skills of CDI, PRIDE and others related to PCIT can be used in school settings, home situations and community/recreation settings, please reference my two books: Toddlers & ADHD and Suffering in Silence: Breaking Through Selective Mutism.

 

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Donna Mac is a licensed clinical professional counselor in her 12th year working for AMITA Health in one of its therapeutic day school locations. Previously, she was a teacher in both regular and special education settings. She has three daughters, including identical 9-year-old twins diagnosed with ADHD hyperactive/impulsive presentation and selective mutism anxiety. Contact her at donnamac0211@gmail.com or through her websites: toddlersandadhd.com and breakingthroughselectivemutism.com.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Volcanic adolescence

By Chris Warren-Dickins January 14, 2019

In the early days, Caroline, a 14-year-old girl, started each session with a chin thrust indignantly at her counselor. She wanted to be seen as a warrior, and she offered answers that were blunt as a sledgehammer.

And why should she drop her defenses? She had seen too many adults — teachers, social workers, friends of the family — try to engage with her at first, and then seemingly lose interest. In the end, she felt that she was just an inconvenience to everyone around her. Why should Caroline believe that this counselor would offer a different type of relationship?

With any new client comes the challenge of forming a therapeutic relationship, but when that new client is an adolescent, there are additional factors to consider. Aside from the legal issues of capacity and consent, I discuss 10 of those therapeutic factors below.

 

1) A holistic assessment: It is important to adopt a strengths-based approach to assessment of adolescents. In addition, it is worth reviewing that assessment more regularly than with an adult client because more things are likely to change with a growing adolescent. As Urie Bronfenbrenner pointed out, a young person’s development is the result of a complex system of relationships that constitute the child’s environment. Therefore, assessments of young clients will include their developmental needs, the extent to which caregivers are meeting their needs, and their family and environmental contexts, including the influence that their school and peers have on them. The assessment should also gauge the influence of technology in the young person’s life.

2) Emotional “distance” from problems: As an adolescent, Caroline needs her counselor to appreciate that she does not have the same “distance” as adults experience from their problems. Adolescents have little control over their lives. They have to stay in the same home or school, even if these things might be the source of their depression, anxiety or other presenting issue.

3) Grasp of emotional language: As a 14-year-old, Caroline still has not developed her emotional language, so volcanic eruptions of anger or shoulder shrugs of apparent indifference are her only means of expressing how she feels. We have to see past the shoulder shrugging, which can easily be interpreted as nonchalance, and open ourselves to the possibility that young clients want to express themselves but just don’t know how to yet.

Images are a useful starting point, even if it is just looking at a series of facial expressions to try and help these clients identify the emotions they are experiencing.

4) The dominance of transition: Transition features heavily in adolescents’ lives. Each year, they are at a different stage of educational development and, each year, they experience bodily changes. On top of all of this, their ideas about who they are and how they fit in with their peers and wider society are in a constant state of flux.

At this level of fluidity, a counselor can offer Caroline some sort of stability. One source of this stability can be the therapist’s professional boundaries. The counselor can also offer Caroline the benefit of his or her life experiences, providing a deeper context than Caroline’s young perspective. But the counselor’s older years and life experience do not provide complete insight, no matter what the client’s presenting issues is, so a person-centered approach is crucial. We, as counselors, do not know Caroline’s worldview until we explore it with her, and we have to be careful not to make too many assumptions.

5) Disruption tenfold: It is hard for adolescents to experience so much transition, but it is even harder to manage at the same time as dealing with mental or physical health challenges, a chaotic home life or a sudden major change experienced by the adolescent’s parents (e.g., job loss, divorce, bereavement).

Because of the volcanic eruptions of adolescence, there is a danger that adolescents will become scapegoats in these situations. Just because adolescents may shout the loudest does not mean they are the source of the problems. Often, parents bring their adolescents for therapy, and these adults are completely unwilling to consider that the need for change might also rest on their own shoulders, rather than expecting just the adolescent to change and the whole family dynamic to become settled.

6) Discrimination experienced by minority adolescents: If an adolescent client is a member of the LGBTQ community or is an ethnic minority, it is likely that they have endured some sort of discrimination. If adolescents have to make sense of this — in addition to the transitions they are experiencing in their bodies, at school and at home — it can be challenging to deal with.

Is it any wonder that we sometimes see volcanic behavior in adolescents in the form of outbursts and defiance, screamed at us in a burning rage? If we are to help these youngsters, we have to see past the behavior that spews out like lava. We must dare to imagine what unmet needs might be fueling this volcano.

To help us, we can consider Abraham Maslow’s hierarchy of needs, and we can assess to what extent our adolescent clients may be getting their basic physiological needs met. Perhaps they are hungry, or there is the constant threat of homelessness hanging over them. Or perhaps their basic safety needs aren’t being met because domestic violence is present in the home. We can continue working our way up Maslow’s hierarchy (love/belonging, esteem and, ultimately, self-actualization) to understand what unmet needs may be fueling what appears on the surface to be irrational and unacceptable behavior.

7) Trauma-informed care: If the adolescent has a history of trauma, it is especially important to see past his or her volcanic eruptions of anger. In a 2017 article in Counseling Today about young clients in foster care (“Fostering a brighter future”), Stephanie Eberts states that therapists need to “help these children heal” by acting as a “translator” of the child’s behavior: “This includes explaining what a child’s behavior means and what motivates it, and then equipping both the child and the parents … with tools to redirect the behavior and better cope with tough emotions.”

8) Testing (to discover and take reassurance from) the boundaries: Adolescents may test boundaries more than adult clients do. Modeling behavior is important, and this is where congruence comes into play. If young clients are constantly pushing the boundaries by turning up late to sessions or missing them entirely, you can communicate the resulting emotion you are experiencing as a result of their behavior.

I like to think of this like a sonar device: Young clients are checking to see if you are still emotionally there and whether they are also still present in the interaction. You can share this with young clients, showing that certain behavior has consequences. Then you can jointly look for a way to resolve the matter.

Psychotherapist Rozsika Parker wrote about parents’ relationships with their children, but the following statements could apply equally to counselors and their young clients. Young clients “need to learn that they have an impact, that it’s possible to hurt” an adult, but it is also possible to “make it up with them.” Parker encourages adults to “show joy, hate, love, satisfaction — the full range of emotions — that will help the child to know themselves.” Parker wrote that she “heard the same note of reproach in their wails when they teethed, as in the studied criticism of me they could launch as teenagers.”

9) The resistant adolescent: As with any resistant client, adolescents need to feel that they are choosing to be in the sessions. But what happens if they are given no choice? If a therapist is working with a young client and the client’s family, and the young client chooses to leave the session early, what should the approach be?

I have heard some therapists adopt the following approach: They tell young clients that they are free to return to the session at any time but that the session will continue with the other family members. I quite like this approach because it avoids sessions becoming hijacked and held hostage by young clients, which might be a parallel process to other times in which these young clients have held more power than they knew how to handle. For example, they might have been forced to adopt a parental role with a younger sibling, or even a neglectful parent, at an inappropriately young age.

10) Mindfulness and meditation: I have seen and heard some of the criticisms of mindfulness and meditation. I struggle with this because, when I was starting out in this profession, my mentors raved about mindfulness and meditation. I need to see where this debate goes, but in the meantime, I cannot help but believe that there might be some value in mindfulness and meditation in our work with young clients.

Everything we offer our clients involves a balancing act between thoughts, feelings and bodily sensations. Society is built to engage the thinking side of our awareness, and this casts a shadow over our feelings and bodily sensations. Yet all three are important sources of information. If we focus solely on our thoughts, we are arguably functioning at only a third of our capacity. Short and simple mindfulness or meditation exercises can help young clients tap all sources of information, while also giving them a moment of relief from the constant demands of life.

 

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Chris Warren-Dickins is a licensed professional counselor in Ridgewood, New Jersey. Contact him through his website at exploretransform.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.