Introduction 

A great deal of attention has been given to our educational system and much of it has not been complementary.  Issues such as student progress, drop out rates, competencies in math, science and geography have all been the source of criticism and concern.  National initiatives have been implanted with reviews that have been more negative than positive.  Some have gone as far as to say that our public educational system in the United States is in chaos.  However, one area that has received little or no attention has been the ability of our educational system to meet the needs of children who are living with the effects of trauma in their past or present.  Some might say that the attention given to special needs children through special education services should address these children.  However, special education attempts to cover a host of causes related to learning difficulties and most of the time services focus only on the symptoms rather than on the problems themselves. 

Handicapping conditions that are observable such as blindness, physical disability, deafness, autism, and even dyslexia are much better understood in educational settings than emotional disturbances and learning disabilities that come from trauma in the child’s life.  For these children the answer is often a referral to the school counselor for the emotional issues that cannot be addressed in class.  But this separation of the emotional and the academic challenges faced by traumatized children is not getting the job done.  A child cannot compartmentalize emotions, thoughts, and behaviors as some adults can.  The whole child comes into the classroom and either succeeds or fails based upon whether all aspects are engaged in the learning process rather than impeding it. 

Some might say that a focus on traumatized children is spending valuable resources on a small group of children.  However, it is important that we learn from disciplines outside of education to get a better sense of the magnitude of the problem of trauma in our society.  It makes logical sense that the majority of children presenting for mental health concerns have histories of trauma.  After all, psychological problems must have some cause.  It may also be commonly known that the majority of incarcerated teens and adults have been abused and traumatized in their past.  Once again, it makes sense that an anti-social disposition toward other people and society as a whole must come from some damaging experiences in life.  It is less known that no less authority than the Center for Disease Control has determined that the primary cause for physical disease in America is early childhood trauma.  According to the CDC, trauma is the primary cause of: obesity, addictive behavior, suicide, chronic employment problems, and the ten leading medical conditions leading to premature death in this country.  It seems that when one stands back and looks at all the representations of failure and not reaching one’s full potential in our culture, trauma stands out as the most significant common factor across settings. 

To those who consider the population of traumatized children in our educational settings too limited to receive significant attention, another look at the data is indicated.  Trauma comes in many forms from child abuse, life threatening car accidents to any serious life event that overrides the child’s ability to cope with the experience.  Every year it is estimated that 5,000,000 new children are added to this list of significantly traumatized children.  Of these children, up to 50% will develop long-term debilitating after-effects of the trauma, including learning problems in school.  Some of the most serious effects of trauma come from child abuse, or betrayal by adults who a child must rely upon for basic needs and even survival.  Of the children who are abused, 94% know the abuser and generally have to rely on the person for protection, producing what some have called the ‘ultimate betrayal.’  When all forms of abuse are considered (physical, sexual, emotional, and neglect) perhaps 1 in 3 children are victimized by abuse during their childhood years.  Not only is the population of traumatized children in educational settings not a small number, trauma may constitute the greatest cause of underachievement in schools. 

What is needed in education, when it comes to traumatized children, is to bring together the substantial new information on trauma, brain development and the causes and solutions to emotional disturbance that exists in psychology and psychiatry and to weave this information into learning theory and progressive academic strategies.  We need conceptual and practical applications of learning approaches and environments where traumatized children succeed rather than fail.  This document will attempt to provide a conceptual framework leading to practical implementation in our experimental learning settings. 

How traumatized children perform in educational settings and why 

Trauma and learning in school do not mix well together.  This is not to say that trauma does not result in significant learning for the child.  The child learns not to trust, learns to be anxious around adults, and learns to be vigilant of the motivations of others.  What a child learns from trauma negatively impacts learning in an academic setting.  If the goal is for a child to come into an academic setting ready to learn, ready to emotionally experience the enjoyment and excitement of discovery, then the effects of traumatic experience will hinder learning in a variety of ways. 

Many traumatized children fail in school, and failure can take many forms.  Children can externalize their difficulties in emotions/behaviors and find themselves in constant trouble and the subject of behavioral restrictions.  Extreme examples of this are children who attempt to get expelled from school thus eliminating the problem of having to face the many challenges of going to school.  Some children sit quietly and can dissociate (day dream) in the classroom and not learn.  An extreme example of the internalizing child is the one who pretends to be ill, doesn’t come to school, or when they are old enough drops out of school altogether.  There are many impacts of trauma that often block a child’s ability to learn in the classroom. 

Trauma produces hypervigilence in children.  This is a survival skill to the child in a setting where basic needs are not provided, but it is not a functional skill in school.  Hypervigilence is often viewed as distractibility.  In part this is due to the child focusing on aspects of the environment that are not part of the learning plan.  The child in science class who is watching the non-verbal messages of a larger boy, wondering about safety during the coming recess break, is not hearing the science lesson. 

Trauma produces serious self-regulation deficiencies.  Often viewed as the most pervasive result of trauma, the lack of self-regulation causes these children not to have the inner understanding, inner strength, or desire to monitor emotional and behavior reactivity to events around them.  This is often observed as intense emotional expression due to challenges in the classroom. 

For reasons that will be explained in the next section, many traumatized children have difficulty putting what they learn into context.  An example of this concept can be seen in the child who can connect the dots that are numbers but cannot see that the dots eventually form a horse.  Being able to put learning into context is an essential aspect of educational advancement.  It means little if the child learns that slaves in early American history were sad and oppressed if they do not understand that slavery was wrong and a violation of human rights.  The common expression ‘not seeing the forest for the trees’ suggests that the many facts, figures and ideas in school must be able to be integrated into understandable and usable information for learning to be sustained. 

Trauma impacts the ability to trust others.  A lack of trust often results in a child misreading the motivations of others, both other students and adult teaching staff.  Some children believe that a difficult learning task was specifically designed to harm them.  Other traumatized children believe that when they are chosen second rather than first, this as a statement of how the teacher values or believes in them.  With peers, these children often presume negative motivations when this is not the case.  Misreading the intentions of others makes it very difficult to find social success. 

In some ways the most important success a child needs in school is social success. School is the first place out of the family that a child begins to develop self-image and understands others and how to interact with the larger world.  A great deal of success in school comes down to the ability to get along with others and to form relationships that can help provide support.  If this first journey into the larger world outside the family ends in failure and conflict, the child’s view of the world can be quickly established in a negative context.  With this in mind, some of the most important learning opportunities in school are at recess, lunch, and in the hallways.  It is in these settings that traumatized children have the most difficulty in school. 

Expecting a child to give their full attention in the classroom is like asking someone who just received a very disturbing phone call to go on with their day unaffected.  The problem with both situations is the affects of anxiety on our ability to focus on the task at hand.  Our emotions are ready to provide us with critical information to inform our decision-making process.  However, our emotions can also run wild with fear and anxiety in situations we either do not understand or believe we cannot handle.  School can produce debilitating anxiety for the traumatized child resulting in the child’s lack of focus and inability to learn. 

Traumatized child often expect the worst and many times experience just what they expect.  In part this comes from the child’s experience that events seldom go the way the child would like and many times the child is powerless and victimized by events and people.  This can produce a negative expectation of experiences in school and a self-fulfilling prophesy of failure.  As the saying goes, ‘If you think you can or can’t, you are right.’ Negative expectations develop into negative self-esteem and the internal belief that internal personal power and interpersonal skills are insufficient to influence one’s life for the better. 

How the traumatized brain functions 

Each of the above issues that are the result of trauma develop and persist in the brain.  Since the primary function of the brain is to maintain and protect the survival of the person, the brain is seriously altered by trauma.  Because trauma by definition is a situation that is beyond the ability of the individual to cope, the brain views traumatic events as a threat to its primary function of survival.  The brain has mechanisms to address threat and these parts of the brain will directly affect the traumatized child in the educational environment. 

The most primitive part of the brain is the brain stem located at the base of the brain.  The brain stem handles basic life support functions such as respiration, circulation and temperature regulation, and all of these bodily systems function without the need for our conscious oversight.  The brain stem also controls the autonomic nervous system which impacts all the other life support systems of the body (heart rate, blood pressure, rate of respiration, etc.).  Input from the environment can increase life support functions of the brain stem, which can adversely affect both personal comfort and a state of relaxed openness to learning.  The brain stem functions can be deescalated, but only when overridden by the neocortex, which will be addressed shortly. 

It can be argued that the section of the brain that is most impacted by trauma is the limbic system in the middle of the brain.  The limbic system has several physical components, but overall it controls emotions, arousal, sexuality, and attachment.  The limbic system includes the amygdala, the fear center or the ‘smoke detector’ of the body.  Whenever the individual perceives a threat of any kind, the amygdala sends out an internal shrill warning signal.  A traumatized child will have such an experience multiple times in a school day, and at times, multiple times in an hour.  The limbic system also plays a major role in distractibility by letting in too much sensory information causing a processing overload.  Trauma impacts on the limbic system also come into play because trauma memories are stored in this part of the brain.  After trauma, all future sensory input will be filtered through memories of trauma.  Such sensitivity can have ominous implications in a school setting. 

The top of the brain and most complex structures are in the neocortex.  This is the region of the brain that educational instruction most often targets.  Here is where the brain not only analyzes information but controls receptive and expressive language development and use.  Most students will come to school ready to process what they learn in this region of the brain.  Traumatized children can have serious neurological roadblocks to processing in the neocortex. 

One of the most important neurological deficiencies after trauma is the impact on mental organization or neuron-integration.  All of the above brain impacts of trauma affect the ability of the frontal lobes of the neocortex to organize input into useable and meaningful information and decisions.  In particular one region of the brain is responsible for overall integration of information and decisions from all parts of the brain and this is the orbitofrontal cortex.  Trauma can significantly degrade the ability of the brain from collecting, analyzing and using information the child learns either in the classroom or on the playgrounds of school.

Elements to avoid in school settings 

Understanding the above impacts of trauma on a student coming to school more concerned about safety and survival than learning math facts, can help us redesign the learning environment for these children.  It is time to get practical and address the do’s and dont’s of a school that provides an optimal educational experience for the traumatized child.  The first place to start is what to avoid in the learning environment for these special children. 

Stress and anxiety – research has determined that for most individuals either too much or too little stress do not promote optimal results.  This is somewhat different for traumatized individuals, but the question becomes how much stress can a traumatized student handle.  The answer is very little without substantial support.  The optimal environment would eliminate as much anxiety as possible because of how anxiety triggers hyper-arousal in the brain, decreasing focus and attention. 

Teaching to the bell shaped curve – traumatized children will be on the low end of the curve and efforts to ‘reach as many as possible’ will generally mean these children will not be reached.  Teaching these children means a specific focus on just those children who are not gaining from traditional teaching methods. 

Serious atmosphere where laughter and enjoyment are rare or discouraged – adults generally view learning as serious work, children view the best learning situations as fun and enjoyable.  Since adults run schools, they tend to be serious atmospheres with excitement, laughter and high energy kept in check.  Serious settings give traumatized children the wrong message that there is reason to be fearful. 

Unsupervised communication among peers – children can be brutally honest and can also be intolerant and hurtful.  Unless adults monitor what traumatized children hear from their peers, the setting will not feel safe to the child. 

Learning through criticism – people do learn from direct criticism but this is not an optimal strategy for the traumatized child.  Criticism is often amplified to give the child the message that they are incompetent or worthless if the child has received this message from adults in the past. 

Uneven competition – competition plays a major role in our culture and in our schools.  Competition can be a good experience for all concerned but special attention must be given to traumatized children.  Fair competition is not always even competition.  If the child is bound to lose, regardless of whether the rules are fair, it is not even competition and will not have a positive result for the traumatized child. 

A constricting environment – what many adults view as methods to maintain order, structure or decorum, many children experience as constricting.  Traumatized children respond to restrictive and constricting settings by fight (acting out) or flight (shutting down) and daydreaming.  Constricting environments are experienced by these children as a message that there is no room for you to be yourself in this setting. 

Rigidity – similar to constricting settings, rigidity is experienced by traumatized children as an authoritarian, inflexible and ‘mean’ atmosphere.  Rigidity is interpreted by these children into negative messages. 

An environment that can be easily disrupted – if a classroom is easy to disrupt, it will ultimately fail to meet the needs of traumatized students.  If by being expressive, questioning, or even acting out the classroom grinds to a halt, the child will either attempt to exert inappropriate power and control over others as a distraction or the child will be fearful that adults can be overcome by children in the setting.  

Elements to enhance in school settings 

Expressive learning – children best learn by doing, not listening or even watching.  Traumatized children bring into the classroom many fears and emotions as well as poorly self-regulated excitement and activity levels.  Expressive learning channels mental, emotional and behavioral energy into learning. 

Predictable structure – while avoiding rigidity, the optimal learning environment for the traumatized child must have comforting structure that signals to the child that safety is assured, adults are appropriately in charge, and students can focus full time on being interested learners in their own childlike fashion. 

More successes than failures – when people try something new they fail many times before they master the task.  Traumatized students give up long before the mastery stage and therefore decline or even refuse to take the risk to do something new.  The child must experience many more successes than failures in small and large ways. 

Adult mediated peer interaction – adults must monitor what is going on among the children because while ‘kids will be kids,’ the traumatized student will experience a lack of physical or interpersonal safety with ‘normal’ communication among children that is negative, teasing, bullying, or demeaning. 

External cognitive structure – instructors must overcome the brain deficits of traumatized children by providing the meaning, planning and connections from outside the child’s brain.  The adults must help the child understand the mental processing steps as well as the end result of higher order reasoning. 

The ‘unschool’ – most traumatized children have been in school before and many times it was a negative experience.  Since their brain filters new experiences through past negative memories, it may be helpful to shed the trappings of “school.”  The unschool looks different, feels different and is different.  What does the child experience walking into the environment?  Is there color, energy, interesting things, and space to be expressive, or is there rigid order, regimentation, posted rules and regulations and constrictions on movement and activity? 

Encouragement through relationship – traumatized children need social support but seldom know how to ask or how to accept such support.  Adults cannot wait until the child is receptive to relationship, the adult must meet the child much more than halfway.  Relationship with a safe adult addresses much of what the child needs in order to begin to open up to the risks of learning and trying new tasks. 

Teaching to the child’s individual learning style – children learn differently and the specific learning style of each traumatized child must be identified to help overcome the many hurdles to learning identified above.  Multidimensional instructional approaches that include auditory, kinesthetic, and visual components can be very effective. 

Even competition – as mentioned earlier, competition can be a learning tool if not overdone and if it is even.  Even competition ensures that any of the competitors have a good chance to win.  If the outcome is predictably determined, it may be fair competition but it is not even and will not be a positive learning experience for the traumatized child. 

Internalized goal setting – although mental reasoning must come from the outside at first, efforts must be put toward the child setting reachable internal goals.  The adults must insure that goals are not only reachable but are also successfully reached before the child can set additional goals.  When children with a losing attitude either win a competition or reach a goal, they seldom know how to handle this experience and initially can be tiresome and demanding of constant attention.  This is attention they need to make up for the past and they will need help to be a good winner and appropriately proud of an accomplishment. 

Enjoyment and fun – if learning is not fun then it will not be sustainable for the traumatized child.  The two primary jobs of a child are to learn and have fun.  It is optimum to do both at the same time when possible.  The optimum learning environment is learning in an enjoyable and fun setting. 

Variety of activities and help with transitions – the opposite of a constricting/rigid learning setting is one that has a variety of interests and activities.  Traumatized children are often poor at self-regulating high energy so they will need outside help even with positive emotional expression.  These children will also need adults to help them prepare for and initiate transitions from one activity to another. 

Choices in areas of the child’s interests – children will have more investment in learning things they are interested in and have some role in choosing.  With creativity, nearly any subject area can be learned through nearly any topic or interest the child has.  An optimum learning environment has room for the child to pursue chosen interests. 

Group/cooperative efforts promoting teamwork – because traumatized children live in a solitary world, positive social experiences are critically important.  These children will not initiate or even willingly participate initially in group learning, but this is a very potent and important way to gain social success and support.  Group efforts must be monitored closely by adults, encouraging of all participants and resulting in a successful outcome for the child to receive the optimal gain. 

School as the doorway to social and personal success in life 

For the traumatized child success in school carries more weight than for other students.  For these children school will either confirm that the world is filled with unresponsive, threatening adults and peers or these children learn that there are places that are safe, stimulating and even fun.  With the vast numbers of traumatized children in our society, it is time that we take a very close look at how to facilitate learning for these children.  One size does not fit all in education, particularly for traumatized children.  The time and effort put into developing an optimal learning environment has the potential to reap huge rewards for children who deserve the very best education we can provide them.  We may need to start small in this endeavor with limited experiments in centers of learning that show educational success with traumatized children.  Simultaneously, our educational system will need to take a critical look at the numbers of children who are being left behind with the educational system currently in place.

The following are excerpts from Traumatic Experience and the Brain, A Handbook for Understanding and Treating Those Traumatized as Children.

There has been an explosion of new information on the human brain over the last fifteen years.  As our technology has improved, we have been able to study how the brain works in ways never before imagined.  This has lead to an avalanche of scientific research and exciting, although difficult to understand, professional literature on the brain–how it develops and how it works. These advancements have helped in many areas of science, but perhaps have been most helpful in understanding the mental and emotional problems that people develop.  This is especially true for children who have been traumatized.

The word trauma can refer to a wide variety of negative experiences—accidents, painful medical procedures, or life changing emotional events; but by far the most common traumatic experience is some form of abuse such as physical or sexual abuse or serious neglect.  Because of the impact of trauma on the developing brain, new advancements in understanding brain functioning have opened new doors to understanding children in our foster and adoptive homes.

As a psychologist and researcher, I am just like you, I can’t get lost in complicating medical and neurological explanations.  I just need to know the answer to one important question, “So what?”  What should I know and what should I do differently based upon all these new studies and all this new scientific information coming out on the brain.  I have spent several years asking this question, and I now share some of the answers I have found, particularly with parents who can use the information to help their children.

The human brain is the most complex organism in the known universe.  It is comprised on 1,000 billion individual brain cells (neurons) that develop 1,000 trillion connections with each other.  An infant at birth has a brain that is only 25% developed, which enables the child to adapt to a wide range of environments.  The brain of a child who is cared for by a loving family will adapt very differently than a child who has a drug addicted mother in a home where domestic violence is common.  We have learned from new research that positive and negative experiences not only are stored in the memory areas of the brain, but experiences also sculpt the developing brain and determine how it will process all new information.  This process goes on at every age even before birth, and just because a child does not have conscious memory of an event (explicit memory), does not mean the brain does not remember (implicit memory).  “So what?”  Well, this helps us see that the earliest experiences of a child will not only be carved in the brain’s memory but the brain itself will develop differently because of the environment.  The brain develops in predictable ways to experiences.  The loving supportive environment produces larger more well developed brain structures that will help the child be smarter, be more inquisitive, and feel safer allowing the brain to put less energy into self protection.  If the child comes into a world with trauma of any kind, the higher regions of the brain grow smaller affecting the child ability to learn and fully understand the world other than how to survive by being ever vigilant of possible harm.

 The brain has many complex components, but basically it can be divided into four areas.  The brainstem is at the base of the brain and handles the less glamorous but essential functions such as breathing, heart rate, blood pressure, temperature regulation and respiration. The diencephalons includes several parts of the brain and controls motor regulation such as walking and balance as well as appetite, sleep patterns, and the memory to ride a bike even after years of no practice.  The limbic system is fundamentally impacted by trauma.  It controls emotions, perceptions, attachment and sexual behavior.  All memories of trauma are stored and impact the individual in the limbic system, but these memories are for the most part unavailable for conscious recall.  The last and highest region of the brain is the neocortex.  This is the largest part of the brain and controls the personality, goals, decisions, and what makes a person a success or a failure in life.  The difference in the overall functioning of the brains of Adolf Hitler and Mother Teresa was minor, but the neocortex produced very different people.  “So what?”  A traumatized child operates from the limbic system and doesn’t understand why they act as they do.  The goal is to provide safety the child experiences so they can operate and develop the higher regions of their brain—decision making, learning from the past, developing values, and forming a personality others care to be around.

The primary job of the brain is survival.  If survival is threatened, the rest of the brain shuts down except for functions that help self-protection.  The brain adapts throughout life, but the strongest adaptation is within the first two years of life.  So what?  Early nurturing care for a child makes a lasting difference as does early abuse of a child.  However, the brain continues to adapt to the environment, so ingrained patterns can be changed with consistent positive experience.

The brain is made up of networks of neurons (brain cells) that communicate with each other.  If mommy is a caring, loving, nurturing experience for the infant, a strong neuro-network develops that says ‘mommy is good.’  If mommy is self-absorbed, unresponsive to the child’s needs when they cry and physically abusive to the child, an even stronger neuro-network develops that says ‘mommy is to be avoided’ to support survival.  So what?  To an abused child, mommy can be any adult in the role of care provider, which may include foster parent, adoptive parent, teacher, grandparent, etc.  The reason attachment is a common problem with many abused children and children in a foster or adoptive home should be clear.  The goal must be to develop new neuro-networks that have to do with safety, predictability, caring, and the child’s physical and emotional needs getting met.  Remember the brain literally changes with every experience.  It will continue to adapt in your positive, nurturing home regardless of how serious past abuse has been.  Yes, Virginia, there is hope!

More “So What’s”

• Consider all problematic behavior within the context of survival to better understand ‘why he keeps doing that?’

• Repetition is important because with every positive experience the impact on the brain grows.
• Traumatized children expect the worst and focus on the negative.  If you understand this, you will be better prepared for it.
• Childhood neglect is the most damaging trauma.  The child must not have basic needs threatened in any way or survival will be all they think about.
• Do not allow radical therapies for traumatized children.  “Holding Therapy,” “Rage Reduction,” and other desperate approaches trigger the memories in the limbic system and make matters worse.
• At the point the child was abused, the brain was focused on survival not learning.  The development the child missed due to abuse will need extra attention.
• Traumatized children will often score lower on IQ tests than their true ability.  Retest when their environment is helping them heal and watch the scores go up.
• The goal in healing trauma is not to keep the child calm.  The goal is when the child becomes agitated to help them learn skills to reduce the agitation.  This repeated cycle is what most helps the child.
• Promote play with traumatized children.  Play is very healing to the brain and the emotions.
• Don’t give up hope!  The human brain is capable of healing in ways we do not yet understand.  It may be a long road to healing and the child may not get there while still in your home, but every situation makes a difference.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References 

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

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

American Psychiatric Association, Arlington, VA. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Executive Summary 

Stakeholders in a comprehensive system of care view psychiatric residential treatment as a dynamic and critical component interfacing with an effective overall mental health system for children (Butler & McPherson, 2006).  To be most effective PRTS must be targeted, responsive, and individualized to the needs of the child and the family and have the following characteristics: 

• Integrated into the overall system of care and includes a continuum of step-up and step- down services within the same provider organization.
• Offers a comprehensive and ecological model of multi-model treatment interventions  into an integrated whole, designed to meet the individual needs of a child and the child’s family.
• Commitment to national standards of excellence, a continuous commitment to quality improvement, and have an identifiable treatment philosophy and approach based upon research and empirical evidence.
• Emphasizes the environment around the child that will necessitate family interventions, partnering with families during and after residential services to best meet the child’s needs.
• Makes an impact on the child’s positive thoughts and perceptions, emotional self-regulation, and pro-social skills and behaviors.

Psychiatric residential treatment services can play several effective roles within the overall system including: a. intensive treatment while maintaining safety, b. a component of a step up/step down plan for a child, c. Treatment of serious disorders that require coordinated multimodal interventions, d. assessing medication level while providing a stabilizing environment, e. alternative to psychiatric hospitalization, and f. a treatment of last resort for children for whom other interventions have been ineffective. 

Less appropriate uses of PRTS include: a holding place for a child waiting for a community placement, destabilizing the child by rapidly altering medications or delving into deeper psychological states without sufficient time to re-stabilize, and when the length of time in PRTS is predetermined before admission due to cost, utilization, or other factors unrelated to the needs of the child. 

The commonly repeated criticisms concerning the lack of research support for the effectiveness of PRTS lack validity.  The comprehensive nature of a multimodal integrated environment presents unusual challenges for isolating variables for causal research.  However, considerable research exists to support the overall effectiveness and efficacy of PRTS. 

When efforts are made to insure that the proper children are admitted to well designed PRTS, the child, the family, and the system of care can expect individualized, client-centered care that can result in positive outcomes for everyone. 

Introduction–Efficacy and Effectiveness of PRTS 

A common goal among all stakeholders in the system of care for children is to develop a comprehensive array of services that is sensitive to the needs of children and their families and provides needed care on a continuum of intensity based upon individualized needs.  For over fifty years there has been a debate concerning putting children in out-of-home placements.  The debate has continued whether this it is the orphan asylum of the past or the psychiatric residential treatment center of the present.  For a variety of reasons, some well deserved, residential care has been plagued by negative stereotypes and pessimistic sentiments (Frensch & Cameron, 2002). A persistent notion that institutional life is contrary to a child’s nature (Whittaker, 2004) has led to “an archaic and inaccurate perception of residential treatment as a single type of ineffective, institutional congregate care for children” (Butler & McPherson, 2006).  However, the long standing debate over residential settings has gradually given way to an acknowledgement that the best system of care includes alternatives for the needs of all children regardless of the level of required intensity (Leichtman, 2006; Butler & McPherson, 2006; Lieberman, 2004).  Therefore the question has changed from whether residential treatment should used, to what is the appropriate and effective use of residential treatment in the new system of care. 

There is considerable literature and research support for the value of residential treatment of a broad variety of types and approaches, particularly for the sophisticated treatment settings that have met the highest national standards of excellence (CWLA, 2004; Lewis, 2004; Friman, 2000; Handweck, Field & Friman, 2001; Larzelere, Daly, Davis, Chmelka & Handwerk, 2004; Lipsey & Wilson, 1998; Lyman & Wilson, 1992; Pfeifer & Strelecki, 1990; U.S. Department of Health and Human Services, 1999). “Residential services are an important and integral component within the multiple systems of care and the continuum of services” (CWLA, 2005). This statement from the largest children’s advocacy organization in the country outlines the new thinking coming from policy makers, system managers, advocates, families, and providers.  The many arguments against the use of residential care of the past, including the comparison of one level of care over another, are out of favor due to improper comparisons and lumping divergent services (Handwerk, 2002; Butler & McPherson, 2006). In its place is a more inclusive and practically position that there will always be a number of youth who require the intensive structure and safety of the residential setting. Whether it is the Child Welfare League of America, the Building Bridges initiative, or the providers themselves (AACRC and others), there is wide support from stakeholders that residential care is an essential and important part of the overall system of care past, present and into the future. 

The psychiatric residential treatment program of today is not the same as programs of the past, including the very recent past.  This fact makes most comparisons to current care and the residential treatment of the past questionable in their validity.  The quality Psychiatric Residential Treatment program of today is not only integrated into the overall system of care, but includes a continuum of step-up and step-down services within the same provider organization.  Such an internal system of care allows for children and families to change levels of treatment intensity without changing key staff such as psychiatrists, therapists, teachers, and mentors.  For child with significant mental health needs, the level of treatment intensity will necessarily change over time if the plan of care is effective. 

What Constitutes Good Psychiatric Residential Treatment Services 

A quality residential program offers a comprehensive and ecological model (Stroul & Friedman, 1996; Wells, Wyatt & Hobfoll, 1991; Hooper, Murphy, Devaney & Hultman, 2000) of multi-model treatment interventions woven into an integrated whole, designed to meet the individual needs of a child and the child’s family.  The best programs start with a commitment to national standards of excellence, a continuous commitment to quality improvement, and have an identifiable treatment philosophy and approach based upon research and empirical evidence.  Effective programs will emphasize the environment around the child that will necessitate family interventions, partnering with families to best meet the child’s needs, and at times may include efforts to identify a family for children without one.  Good residential programs know the target populations that they are most effective with and have evidence based approaches for these populations.  Good programs make positively impacts on the child’s positive thoughts and perceptions, emotional self-regulation, and pro-social skills and behaviors.  The best residential programs are integrated into a community of stakeholders who have input into a continual unfolding of quality interventions in an overall environment of safety, respect and effectiveness. 

The Best Use of Residential Treatment 

For too long residential treatment has been relegated primarily to the placement of last resort.  In some situations it may be the case that a child has been unresponsive to treatment that is less intense or insufficiently environmentally integrated, thus necessitating the strengths of a residential setting.  The use of residential care as a “last resort” is still a possible role but there can be other roles as well: 

Intensive treatment while maintaining safety—Some children cannot be effectively and safely treated in a family setting.  Examples of this are serious violent behavior, firesetting, and significant sexual behavior. 

One component of an overall treatment continuum—At times the needs of a child may warrant treatment in a variety of settings from maximal to minimal levels of intensity as treatment progresses.  Residential care can be an important part of the plan including a back up to serious deterioration in levels of care in community settings. 

Treatment of serious disorders that require multimodal intervention—Children with the highest acuity of psychiatric needs often require a complex array of integrated services in a single setting.  An example of this are complex trauma disorders where up to a dozen specialized intervention strategies may be needed (Connor, Miller, Cunningham & Melloni, 2002). 

Safely assessing psychopharmacological intervention—A child may have serious emotional or behavioral destabilization when medications are significantly altered.  For children with several medications, it may be important to insure safety for the child and all concerned while the medication assessment process takes place. 

Alternative to hospitalization—A well designed psychiatric residential program can be an effective alternative to hospitalization for many serious children.  This can provide advantages including: keeping the child and family in the community, intensive care in a less restrictive setting, and a significant reduction in cost allowing a length of stay appropriate for the child. 

There are also ways that residential treatment should not be used.  It should not be a default setting for a child who has completed treatment but is waiting for a placement.  A residential setting should not be allowed to destabilize a child’s mental health, such as changing medications or opening painful psychological issues without sufficient time to follow through with the ramifications.  While there are children who have been shown in research to improve with short stays of six months or less in residential care (Blackman, Eustace, Chowdhury, 1991; Leichtman, Leichtman, Barker & Neese, 2001; Shapiro, Welker & Pierce, 1999), this is based upon a short-term approach of lowering the expectations of treatment through modest and selective goals such as primarily addressing the issue that caused the removal of he child from the family home (Leichtman & Leichtman, 1996).  However there is still a place for longer term treatment with specific childhood disorders that are not responsive to short-term interventions (Zegers, Schuengel, van IJzendoorn & Jansserns, 2006; McNeal, Handwerk, Field, Roberts, Soper, Huefner & Ringle, 2006; Greenbaum, Dedrick, Friedman, Kutash, Brown, Lardieri & Pugh, 1996).  Residential treatment is improperly used when the length of intensive residential treatment is predetermined before admission due to cost, utilization or other factor unrelated to the needs of the child. 

Efficacy and Effectiveness of Residential Treatment 

It is commonly stated that residential treatment has been shown not to be effective.  A closer look at efficacy and effectiveness tells a different story. While there have been weaknesses among the providers of residential care over the years, there have also been very effective services delivered in a residential setting.  This point raises an important distinction between an intervention and a setting.  Too often this distinction is misunderstood resulting in ‘apples and oranges’ comparisons (Butler & McPherson, 2006).  For example, an evidenced based intervention can be effective in a variety of settings, or the wrong evidence based intervention in a specific setting can be highly ineffective.  When discussing whether a placement is the best choice, both the setting and the interventions to be used are both important considerations. 

Science is informing the mental health world at an unprecedented pace.  Objective research is increasingly being considered to inform decision makers, parents and providers as to what to do more of, and what to discontinue.  Science considers all aspects of a situation to form an opinion, not just factors that confirm previous biases. Because there has been a fifty year debate over putting children in residential setting, both sides have presented data to enhance their argument, for or against. We must now move beyond previous biases and look toward objective science. 

Whether a treatment setting works depends upon both efficacy and effectiveness.  Objectively speaking there is research to support strong efficacy in residential care.  At the same time there are consistent questions as to the effectiveness reflected in research on residential treatment (Hair, 2005).  This apparent contradiction points to the difficulty in evaluating whether a complex setting works or not.  The answer often depends upon the way the question is framed, as well as how outcomes are measured.   

There has been decades of research evidence of efficacious treatment of children and adolescents in all settings.  When children who receive a broad variety of treatments are compared with control groups of children receiving no treatment, the treatment group is consistently superior with an effective size from .7 to .8 (Casey & Berman, 1985; Baer & Nietzel, 1991; Burns, Hoagwood & Mrazek, 1999; Grossman & Hughes, 1992; Hazelrigg, Cooper & Borduin, 1987; Kazdin, Siegel & Bass, 1990; Shadish, Montgomery, Wilson, Wilson, Bright & Okwumabua, 1993; Weisz, 1987; Weisz, Weisz, Han, Granger & Morton, 1995).  Some treatments and some settings have shown better results than others, but treatment efficacy research provides strong and consistent evidence that providing psychological treatment to child clients is much better than not doing so. 

Much has been made of the scarcity of causal research on residential treatment.  The reason that effectiveness research on residential settings has been either mixed or lacking is primarily due to the complex weave of multiple treatments in an ecological setting.  Such an enriched setting of multi-modal treatment variables is not conducive to empirical causal research.  Moreover, “the very characteristics that are likely to make (treatment) effective make them more difficult to describe and evaluate…numerous elements of family and agency life weave together with the therapeutic intervention and potentially decrease the chance of finding a positive treatment effect when there is one” (Hair, 2005). Butler and McPherson point out that this lack of empirical evidence in part is based upon the challenge of measuring what residential care does best.  They report gains such as:  enhanced safety, truancy reductions, consistent medication management, reduced hospitalizations, consistency, structure, caring and nurturing, limit setting, psychosocial support, self-esteem role modeling, time to self-reflect, and focus on mental health issues, all of which are invaluable to the child but are complicated to objectify and analyze. “Thus the literature does not actually reveal much helpful information” (Butler & McPherson, 2006). 

Some of the research showing marginal or no positive efficacy makes the conceptual error of comparing some new type of treatment intervention with the traditional treatment setting of residential care.  There are studies that indicate poor outcomes with residential care (Burns et.al., 1999; Greenbaum et.al., 1996; Friman, 2000; Ruhle, 2005).  Some of these studies again address a setting, not specific treatment interventions.  Research on essentially all settings can find poor outcomes (families, hospitals, foster care, schools, etc.). For example, while there is considerable evidence of effectiveness for some uses of family based treatment foster care, other uses have been found to be contraindicated (Farmer, Wagner, Burns & Richards, 2003), or less effective for some populations than residential care (Drais-Parrillo, 2005). Treatment settings in themselves do not insure effectiveness, this can only be done by quality interventions within a treatment setting.              

When treatment interventions are the subject of research residential settings the results often show strong improvement (Landsman, Groza, Tyler & Malone, 2001; Hooper et. al., 2000; Weiner & Kupermintz, 2001; Burns et.al., 1999).  Research has shown long-term maintenance of gains in clinical functioning, academic skills and peer relationships (Blackman, Eustace & Chowdhury, 1991; Joshi & Rosenberg, 1997; Wells, 1991). 

Two predictors of long-term positive outcomes deserve to be specifically mentioned.  The quality of the therapeutic relationship in therapy has been found to be one of the most important predictors of long-term success (Pfeifer & Strzelecki, 1990; Scholte & Van der Ploeg, 2000).  In a recent study on attachment representations, children in residential treatment improved in their forming secure attachments and decreasing their avoidance and hostile behavior.  However this finding was true only for children with longer stays in residential treatment.  The study reported, “When the duration of treatment is extended, the personal attachment backgrounds of clients and treatment staff increase in importance (Zegers, Schuengel, van IJzendoorn & Jansserns, 2006).  The other long-term predictor of success is positive outlook, life satisfaction and hopefulness.  In a 2006 study children in residential treatment increased their hopeful thinking and general well-being, while decreasing psychopathology (McNeal, Handwerk, Field, Roberts, Soper, Huefner & Ringle, 2006). Attitudinal and cognitive variables such as hope have been found to predict outcomes above and beyond psychopathology (Hagen, Myers & MacKintosh, 2005). This study on hope found the children with the highest levels of psychopathology made the most gains after 6 months of residential care. 

Therefore a quick statement on the general findings of research indicate: strong support for providing treatment services to child over no treatment, mixed results when evaluating the setting, and strong support for effectiveness with specific treatments in residential settings.  It can therefore be said that, in general, treatment provided to the child will be better than none at all, and it is the treatment interventions used in the residential setting that are the determining factor of efficacy and not the setting itself. 

The Right Target Population for Psychiatric Residential Treatment 

Intensive treatment services in a residential setting are restrictive and potent and should only be a part of the plan of care for a child if needed.  There is common agreement that care should be taken before placing a child out of a family setting and particularly when placing the child in a PRTS program.  It is important that guidelines exist concerning the right target population while not being so prescriptive that children ‘fall through the cracks.’  To avoid legislating children out of a needed service, it is essential that the individual child’s needs must come first, and the child matched to the proper level of care intensity.  The overall criteria for such a restrictive setting is to include only those children who cannot receive the treatment they need while remaining in a family setting.   The historical criteria for admission to PRTS have been: 

1.  Other treatment resources available in the community do not meet the treatment needs of the child.
2. Proper treatment of the child’s psychiatric condition requires services in a psychiatric residential treatment setting under the direction of the psychiatrist.
3. The services can be reasonably expected to improve the child’s condition or prevent further regression so that psychiatric residential services may no longer be needed
4. The child has a principal diagnosis of Axis I of a completed 5-Axis DSM diagnosis that is not solely a result of mental retardation or other developmental disabilities, epilepsy, drug abuse, or alcoholism. 

These criteria have provided guidelines while allowing for individual needs to be considered.  If proper treatment resources exist in the community, if the child does not need psychiatric oversight, if the treatment can help or prevent further deterioration and if they child has a mental health diagnosis, then the child can be considered.  As the system focuses on improving community resources, more children would be screened out due to the first criteria. 

The one screening tool that has been used in the past is the Childhood Acuity of Psychiatric Illness.  It has been used to inform the admission and discharge decisions but has not been the sole criteria.  Like the CASII, where it is possible to have an overall low acuity score yet be appropriate for intensive treatment due to high risk behavior, the CAPI scores do not address all areas of need or interest when making admission decisions.  Therefore it cannot be used solely as an indication of proper or improper placement decisions. 

There is general agreement that treatment should be individualized, strength-based, and integrated.  Therefore it is important to insure that admission and discharge decisions are individualized and not based upon a score or single or multiple indicators not related to the needs of the child. 

It is important that the child have a serious mental health issue to be appropriate for PRTS.  However, the treatment needs of the child should be the primary consideration and not the diagnostic category, which often varies by practitioner.  Frequently a child’s diagnosis changes when the provider changes.  Diagnostic categories are not discreet in many cases and children needing PRTS care typically have multiple Axis I diagnoses.  The diagnosis of a child at admission has been found to be a negligible factor in success at discharge (Hair, 2005), thus the specific diagnosis should not be used as a factor to screen a child in or out of PRTS. For example, lf a child is dangerous due to a mental health diagnosis, the child should not be screened out due to which diagnosis the child has been given.  Using another example, if a child is suicidal and has a serious oppositional defiant diagnosis, the child should receive the treatment needed in a safe setting, which could necessitate a PRTS level of care, regardless of the diagnosis. 

Research consistently indicates that children with supportive families do better in general, do better in school, do better in treatment, and do better coming out of PRTS.  This makes logical sense.  However, true trauma informed care necessitates that a child who is unlucky enough to receive poor family support or who has lost his or her biological family, should not be further neglected by the system and prevented from receiving PRTS care if that is the indicated need.  Developing an aftercare resource becomes an important part of the plan of care.  Trauma informed care also requires that the treatment reflects the child’s past, provides effective trauma treatment, and insures safety, predictability, and stability of placement while intensive trauma treatment is provided.  For a seriously traumatized child, focusing solely on stabilizing a child’s behavior without providing intensive trauma treatment is not individualized, nor is it responsive to the needs of the child and family. 

Summary 

Psychiatric residential treatment is an important and essential component of the mental health system of care.  The best treatment programs are ecological in orientation and combine all the needed components to best help the child and family.  Despite the fact that ecological treatment settings are not conducive to quantitative causal research designs, they have been shown to be some of the most effective services for children with multiple needs.  Psychological treatment has shown decades of strong support across settings and has been shown effective when interventions in residential settings are considered rather than the setting itself.  The family must be involved in both decision making and intensive treatment along with the child.  If a child has lost his or her family for whatever reason, the child should not be further neglected by not receiving the level of intensive treatment services needed.  The right target population should be afforded PRTS.  Adhering to the historical criteria has shown that the right children receive the right level of care.  Reliance on any one score, instrument or factor alone is contraindicated for PRTS as it is for any placement decision for a child.  The admission decision on a child must be individualized with the needs of the family taken into consideration.  The treatment must conform to the child and family and not expect the child to conform to the treatment.  This includes both treatment programs as well as the overall system of care.  When a PRTS program is carefully designed with multi-modal treatments to address the complex needs of the child, and individualized in partnership with the family, this intervention can turn the most seriously challenging children in the system of care into some of the most improved consumers.  Such an outcome is one that is desirable to all stakeholders in the system of care.  

References 

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Adoptions can be much like marriages:  Too many dissolve with pain for everyone; others stay together but everyone is unhappy; some get by with everyone lowering his or her expectations; and too few are a wonderful experience of loving, learning, and growing for all concerned.  To foster success, adoptions need as much care, thought, and skill training as marriages.  Marriages and adoptions fail partly because those involved do not know what they are actually saying yes to and discover they don’t have what it takes to handle the reality they find.  The goal becomes not only how to survive the reality of the adoption but how to thrive with the challenges involved. 

Maintaining More than Your Sanity 

Maintaining a healthy adoption can be compared to maintaining an automobile.  There are issues that need attention, and, as the ad goes, “You can pay me now or pay me later.”  Here are some comparisons:

Check the radiator                    Keep it cool, don’t overheat              

Check the steering/brakes       Stay in control at all times                   

Keep the battery charged         Keep your energy                              

Tune up for performance          Maintain your power                         

Check the plugs                         Keep your spark                             

Check wear on tires                  Realize you are wearing down before you burst. 

Contained in each of these suggestions is all you really need to know about maintaining health in an adoption.  The best truths are simple ones.  A recent best seller tells us that we learned in kindergarten everything we need for a happy, fulfilled life.  Well, some of us may have gotten it all the first time, but most of us could use a refresher.  If you got it all at first, then stop here.  But if you need to hear a bit more, read on. 

Why Do Adoptions Fail? 

There are many reasons for disrupted adoptions, but they all boil down to one overall issue.  Families choose to adopt for many reasons, but they want to do a good thing for all concerned.  Although they know there will be struggle, they do not adopt to put everyone through great pain.  Adoptions fail when a commitment to a child begins to harm commitments to other loved ones.  If it gets to the point that something has to go, it will probably be the adopted child.  There are two important perspectives here: 

The family.  There may be many reasons to adopt, but in the end a family decides it has room in its members’ lives and hearts for a new family member.  But what are they to do if their offers of love and affection are met with lack of interest or even hostility?  The family can understand that life may have been difficult for the child but believe all that can change if the child simply accepts the loving care of this new family.  After weeks and then months of a child letting the family know that he or she wants neither their home nor their heart, all that the adoption seems to be bringing everyone is pain.  Maybe the child would be better off somewhere else, and clearly the family members were better off before all this started.  This often becomes the final chapter, one filled with failure, guilt, and grief for everyone. 

The child.  All adopted children have experienced deep loss or they wouldn’t need a family.  Most special-needs children have experienced much more than loss.  Fearful and adrift in the foster care system, the child is informed that he will soon get a new family.  But do people realize what family may mean to the child—the ones that were supposed to always be there for you but weren’t?  To the child, Mom and Dad may mean someone who didn’t care, or worse, someone who was very abusive.  The child has probably been in numerous homes and schools.  Such children can’t put their heart on the line again unless they know it will be safe, so they test the family.  Sometimes their testing is misinterpreted by the family, and a negative cycle begins.  The worse it gets, the more fear arises and then more testing occurs.  The child begins to see the family stop trying and waits for the caseworker to appear and once again move the child from a home that was supposed to always be there for him or her but wasn’t.  This confirms again that the world is a cruel place where you have to fight to survive and avoid being vulnerable at all costs.  And the world has another antisocial personality. 

How can these traps be avoided?  How can the process not only last but be a good experience for everyone? 

What Successful Adoptions Look Like 

Successful adoptions involving a child with special needs tend to have a lot of TLC.  Tender loving care, you say?  Absolutely not!  Tender loving care is almost always in abundant supply in failed adoptions with these children.  That just may be one of the principal problems.  In this case TLC means something very different: 

T = Translating correctly what is really going on with the child in order to understand where the child really is.  It is commonly known that manipulative teenagers (and aren’t they all) talk in opposites.  It is often a safe bet to retranslate what they are saying to get closer to the truth.  Practice by retranslating the following:  I don’t want rules; I’m not worried about my future; I am all caught up on my schoolwork; I’ll be home early tonight.  This same principle works with special-needs children. 

L = Learning from the challenges of adopting a difficult child becomes one of the indicators of success, not how smooth it’s going for everyone.  If you want smooth, get some Jell-O.  But adopting is not smooth—it is trouble or challenge, depending on your point of view.  The more you see it as a challenge to learn from, the better the candidate you are to adopt a difficult child.   

C = Stay in control at all times in all situations involving the child.  These children did not get difficult on their own; they had lots of help from chaotic, abusive, and neglectful families that could not provide a safe or secure home.  Constant control sounds pretty heavy, but if you adopt one of these children, he or she will constantly test to see just how in control you are.  If the child is able to gain control, everyone loses; if the child can’t, everyone wins.  It’s that simple. 

TLC – Translating, Learning and Control – is easier said than done.  But here is part of the point – what does a difficult adoption offer you?  It offers an opportunity to grow yourself, as you give a deserving child a fresh chance to be part of a family. 

Seven Strategies for Success 

1.  Understand the real needs of the child.  It is not often helpful to listen to the child’s words or even to accept the child’s behavior at face value because of the opposite issue.  If the child has had an abusive or neglectful past, then his or her needs are pretty straight-forward despite the way the child acts.  These children need the following:            

• Safety.  Will I be safe in a nonviolent environment where my basic needs will be met?           
• Security.  I need a structured situation where a parent is in charge and I can just be a kid.           
• Acceptance.  I need people who can accept me as a person even if they don’t like or accept my behavior.           
• Belonging.  I need to belong to someone; I need to be connected to others and learn to give and receive affection.           
• Trust.  I need to learn to trust and be trusted; I need to be treated fairly, with honest, to respect, and firmness.           
• Relationship.  I need to be in relationships with others in a way that no one is victimized and both sides are enhanced.           
• Self-awareness.  I need to learn how to make changes in my personality and behavior by self-understanding.           
• Personal worth.  The final indicator of my being a success as a person is, Do I believe in myself and my own worth? 

2.  Positive discipline is the quickest route to your control and to the child’s personal worth.  Techniques include separate the child from the behavior; don’t punish—discipline (which means to teach); don’t let “time-outs” become a disguised punishment; use logical consequences; don’t ask the child to lie by asking questions you know the answer to; avoid power struggles; have the child fight with himself/herself, not with you; keep your sense of humor and don’t let the child decide what you will feel; and allow the child to change and be more responsible by not always locking the youngster into past behaviors. 

3.  Learn to win the manipulation game.  Don’t let the child use your rules against you.  Don’t be completely predictable to a manipulative child; you’ll become an easy target.  Keep the child off balance when he or she is trying to beat you.  In general, if the child is manipulating to get something, do your best to prevent the child from getting his or her way or you will get more manipulation (because it worked).  Stay a couple of steps ahead by predicting what the child might do and what you will do in return.  Don’t respond emotionally; you won’t think very creatively then.  Parenting is best done by a team; talk over your next move and get advice and ideas.  If the child has you on the run, the child will win the manipulation game and both of you will lose. 

4.  Get the help you need from the right source.  Quite frankly, some counselors who don’t understand these children can make the situation considerably worse.  It is not much of a challenge for a manipulative child to be “perfect” an hour a week in someone’s office.  If the counselor starts looking at you like you must be the problem, get someone else.  Ask prospective counselors about their experience with adoption, abused children, and kids with attachment problems.  Or better yet, go to a counselor who comes highly recommended for his or her skills with a child just like yours.   

5.  The only given is that this type of adoption will be difficult; it does not have to be terrible.  The difference is something you have complete control over – your feelings and sense of humor, the world just isn’t funny anymore,” and adoption is like that. 

6.  Make sure you are more than a parent.  If you are a parent twenty-four hours a day, you have become pretty dull.  Be a wife, a student, a hiker, a volunteer, a square dancer, an artist, a husband, or whatever, but don’t get stuck in the parent role where there is a whole lot more giving than receiving.  Batteries don’t last long if they never get recharged. 

7.  Don’t get in a hurry.  The saddest failed adoptions are the ones where the child is desperately testing and the parents call it off.  If only they could understand that the desperation is an indicator that the testing is nearly over and that they have almost passed the test.  It has taken a long time for these children to be hurt; it takes time for them to be vulnerable again.  But don’t continue down a road that is clearly leading nowhere.  Get some good help from a counselor who has a good road map – there may be a much better road to get where you want to go. 

Final Thoughts 

So what do you think?  If it sounds like a lot more work than you thought, don’t feel alone.  Just consider – if parents knew all they would have to endure with their birth children, would they be so eager to go through with it?  Make no mistake – parenting is the world’s most complex and difficult job.  It is even more challenging if you have to pick up the pieces that someone else has failed with.  If all this is more than you can imagine, then get a pet.  But if you want the ride of your life, if you want to be the most substantial influence in a young person’s life, and if you want to learn more about yourself than you thought was possible, then boy, does CSD have a deal for you!  

Dave Ziegler is the founder and executive director of SCAR/Jasper Mountain, a nationally recognized treatment program for traumatized children.  Dave is a psychologist and holds four professional licenses and has been a foster parent for many years.  In addition to his work at SCAR/Jasper Mountain, he speaks throughout the country to parents and professionals and is the author of Raising Children Who Refuse To Be Raised, and Traumatic Experience and the Brain.  This article is drawn from his 2005 book Achieving Success With Impossible Children, Winning the Battle of Wills. His newest book, Beyond Healing: The Path To Personal Contentment, will be released in 2007.  

If you have a challenging child in your home, you are not alone.  With the numbers of children in foster care, the increased number of domestic and foreign-born adopted children, and children in biological homes that have experienced divorce and other domestic problems, parents today are searching for answers to the increasing challenges presented by troubled children.  Some of these children can make parents crazy, because parenting approaches that work for other children don’t help at all; and even worse, what worked with the child yesterday, doesn’t work today.  Sound familiar?  

I know what you are thinking, “another one of those articles about being a good parent-with an expert saying: be consistent, stay calm and make sure the child gets plenty of tender loving care.”  Not so fast, in some cases this advice is a part of the problem rather than a part of the solution.  And if you haven’t already asked this, I will do it for you, “So what makes this guy an expert anyway?”  Good question.  There is only one thing that makes someone an expert in parenting difficult children and that is to have actually done it, and done it successfully.  Starting as a foster parent with one child at a time, my home has evolved into one of the top treatment centers in the United States. The type of children we go out of my way to help are those that refuse to ask for, or even accept, our attempts to help or to parent them.  Perhaps I have a screw loose, but I see these children as my best teachers.  So if your child is happy to see you when she comes home from school, if he volunteers to help out around the house for free and can be found on weekends cleaning his room while singing “Don’t Worry, Be Happy,” then this article is not for you.  I hear stories about such children, but I have never parented one.  My foster home turned into a group home, and then into a treatment center over the years.  But my family is still here 23 years later getting children who are grumpy (and worse) off to school each morning, and seeing if we can introduce each of them to a world they don’t believe exists-one where they can come out a winner.  Do they eventually get it?  Yes, in nearly every case.  But before they learn to touch the stars, they have to learn to firmly plant their feet on the ground.  If you are with me so far, then let’s get to work on parenting difficult children. 

What I have found that works with troubled and difficult children is a combination of staying focused on the goal for each child, and knowing what I need to be doing more of, and what I need to be doing less of.  My goal is a progression of having each child experience the following and to do so in the correct order-experience safety, security, acceptance, belonging, trust, relationship, self-understanding and personal worth.  These critical components of being a successful human being must come one at a time as in stair steps, and rely on the foundation of the step that came before.  Without safety you can’t have security, without acceptance you cannot feel like you belong, and without trust you cannot have a successful relationship.  I ask myself what step I am on with each child I am working with and keep focused on the goal to get to the next step-one child and one situation at a time. 

What I need to be doing more of can be broken down to the following: 1. Translate the child’s behavior and energy to understand what is going on inside of him (don’t get sucked into his words, works are seldom helpful), 2.  Give attention to things I want to see more of (don’t spend your day giving most of your energy to misbehavior, because what you give attention to, you get more of), and 3. Lead with thinking and not with emotions (don’t let the child decide how you are going to act or feel, remember that feelings are easy targets for children who want to wound others).   

So what about being consistent, staying calm and tender loving care?  I find consistency overrated.  This is not the case with responsive children, because they need your consistency.  With troubled, angry and/or manipulative children, they will use your consistency against you.  To disrupt a child who gets stuck in the same negative behavior habits, I suggest creative inconsistency.  What this means is you must first disrupt the cycle between you and the child.  He is used to doing his thing (misbehavior) and waiting for you to do your thing (correcting the behavior).  You don’t like this cycle, but your child does like it because he feels in control of you and the environment.  If you are tired of this dance, then change it.  First short circuit the behavior pattern, and then intervene more effectively.  For example, if your bundle of joy has a habit of not liking dinner each night and colorfully sharing her culinary review, then start the dinner by saying, “Jessica, you only get dessert tonight when you have found something wrong with every aspect of tonight’s dinner.”  After the child looks up at you wondering, “Has she finally lost it?” she then has a dilemma (that I love to put children in)–do I follow directions and criticize, or do I refuse to criticize and break my pattern.  You win either way.  We call this prescribing the symptom, and it can also be called putting the child into a therapeutic bind.  The goal is not to frustrate the child, but the goal is to frustrate the behavior.

Most parenting classes will tell you to stay calm.  That is fine most of the time.  However, when I get ignored by children (this is frequent in the early stages), or if the child wants me to repeat essentially everything I say, I might try yelling my thoughts and directions.  I don’t do this in an angry way, just a loud way.  Troubled children do not like yelling in the house if the yelling isn’t coming from them, so they always ask me, “Why are you yelling?”  I tell the child that I am saving us both the time of either repeating or having them miss what I have to say.  When they ask me to stop it, I offer them a deal that I don’t need to yell if they listen and don’t need things repeated.  Welcome to the world of reciprocity. 

As for tender loving care, the quickest way for a child to put a parent in the funny farm is to reject every overture of caring and love.  Love may have been all the Beatles needed, but they were not raising troubled children.  Difficult children need love all right, but it needs to come in the form of teaching the child the lesson that life and relationships are two-way streets, what we put out to others has a lot to say about what we get back.  So save your tender loving care until the child has moved beyond manipulation, self-hate and perpetual rudeness (yes, with the right steps they can move beyond these).  In the meantime give them a different type of TLC-Translating what is going on with them, Learning from every situation to be a better parent to this child, and staying in Control of your behavior, your emotions and the energy in your household. 

With those basics as a foundation, let’s look at a number of strategies for successful parenting: 

• Take care of yourself-if you don’t do it, who will?  We all have rechargeable batteries, but like a flashlight, if we don’t take the time to recharge, our light becomes dim in a hurry. 
• See below the surface of behavior-what you can see is only a small part of the problem.  Behaviors are the result of what a child thinks and how he or she feels.  We must go deeper than managing behavior. 
• Be firm in a loving way-if we are too firm the child links us with past abuse, if we are too loving they may not respect us.  Strike a firm and friendly balance. 
• Never stop working on yourself-we all make mistakes parenting?  I use my mistakes as a model for children.  I admit the mistake and take personal responsibility, and then I take the necessary steps to repair any damage done.  How can we ask a child to do this if adults have not taught the child how by example? 
• Make sure the child feels your support-don’t wait until things go badly before showing your support.  When things do go badly, with every correction give the child the message you believe that he or she can do better.  “We don’t grab things from others just because we want it in this house.  I want you to think about this and I know you can come up with a better way to handle it.  When you do, let me know and you can have your turn.” 
• Always give more praise than criticism-criticism fits the child’s negative self-image, praise does not.  If you want the child to be more positive, he must hear more positive messages from you. 
• Practice the “New Day”-just because the child has been doing poorly in the past, start over each day and give them a chance to improve.  If the child is ready to move beyond misbehavior, make sure you are ready to let them.  This is one reason why extended consequences, such as grounding the child until age 21, are not recommended. 
• Don’t let the child lower your expectations-you generally get somewhat less than you expect from a difficult child.  If you expect a lot or a little, you will get somewhat less.  High or low expectations, its your call (by the way, the child prefers lower expectations). 
• Practice “No-Lose Parenting”-do your home work, use your superior mental skills, do your best, don’t give up, don’t expect an immediate return on your investment in the child, and remember, your responsibility is what you have become more so than who the child chooses to become.  If you do all this, how can you lose?  

OK, so I haven’t told you everything you need to know to be successful with your difficult child.  Fair enough, so the little challenge in your home is going to take some extra study and work?  That is why this parenting approach has two textbooks with very appropriate titles:  Raising Children Who Refuse To Be Raised and Achieving Success With Impossible Children.  The ideas in these books can change the whole game with your child.  Working with tantrums, sexual behavior, lying and stealing, and teaching responsibility, positive discipline, are all covered in the style of this article. Obviously I believe the ideas will help you.  I believe this because the ideas were all taught to me not in graduate school but by the children I have parented.  Did I forget to say, parenting a difficult child can even be fun?  You will have to read more to find out about that (I warned you about my loose screws).  Happy parenting!