ࡱ> 7  ]bjbjUU &7|7| Yl < TwM` L LLLLLLL$P ;RFMM1 1M111   L1L1122IL T ௬9`9( J.LGM0wMJRXL1F.C.B.C. Foundation for Children with Behavioral Challenges www.fcbcsupport.org Understanding and Helping Children with Behavioral Challenges This handout has been prepared by P.T.E.K. to assist caregivers in understanding and helping children with behavioral challenges. It draws heavily upon the research and work of Dr. Ross Greene (author of The Explosive Child, Director of the Collaborative Problem Solving (CPS) Institute in the Department of Psychiatry at MGH, and Associate Professor in the Department of Psychiatry at Harvard Medical School), and Dr. J. Stuart Ablon (Co-Director of the CPS Institute and Assistant Professor in the Department of Psychiatry at Harvard Medical School). We believe that an approach, such as CPS that is based on a thorough understanding of our childrens strengths and interventions that address their vulnerabilities will allow them to become successful and responsible members of society. It s important to note that this handout provides only an overview of the CPS approach. Therefore, we strongly recommend reading the book, The Explosive Child, attending a full day CPS workshop (refer to:  HYPERLINK "http://www.ccps.info" www.ccps.info), viewing the new video: Parenting The Explosive Child (available at www.ccps.info) for a more complete understanding. We also encourage taking advantage of information, resources, and support available at our web site:  HYPERLINK "http://www.explosivekids.org" www.explosivekids.org. The CPS approach is based on a thorough understanding of each childs unique strengths and vulnerabilities. While this handout, along with the attached CPS Pathways Checklist (developed by Dr. Greene) can assist caregivers in gaining an understanding of why a child is struggling and how to help, it is important to note, that many caregivers find that professional evaluations and guidance are often needed to embark and carry out the approach. Seeing Children With Behavioral Challenges In a New Light Behaviorally challenging children have typically been poorly understood. All too often, their difficult behavior is seen as willful and goal oriented, the product of poor parenting (inconsistent, non-contingent). In other words, that the child has learned that explosive/aggressive behavior is an effective means of getting attention or coercing others into giving in to their wishes. This has led to interventions that focus on gaining greater compliance with adult directives through the use of rewards and punishments. Extensive study and research conducted by Dr. Ross Greene and others indicate that for the majority of these children, the basis of their difficult behavior can best be understood as a learning disability or developmental delay in the domains of flexibility and frustration tolerance. In other words, because of a variety of factors, most of these children lack the crucial cognitive and emotional skills that are essential to handling frustration and demands for flexibility and adaptability, or have significant difficulty applying them when they are most needed. These children are not choosing to be explosive or non-compliant, any more than a child would choose to have a reading disability. With a more accurate explanation, the stage is set for adults to be part of the solution: re-establishing positive relationships with these children, creating experiences that will provide the training and practice in problem-solving skills, flexibility, and frustration tolerance that they need to be more successful. The good news is that when we apply the same compassion and approach we would use with an LD child-these children do better (and we adults do better)!!! Typical View of Difficult Children: Guiding Philosophy: Children do well if they want to. Explanation: Childrens difficult behavior is attention-seeking or aimed at coercing adults into giving in. Goal of treatment: Induce children to comply with adult directives. Tools of treatment: Use of reward and punishment programs to give children incentive to improve behavior. Emphasis: Reactive focus on management of problematic behavior after it has occurred. Dr. Greenes CPS View: Guiding Philosophy: Children do well if they can. Explanation: Childrens difficult behavior is the byproduct of a learning disability in the domains of flexibility, adaptability, and frustration tolerance. Goal of treatment: Teach children lacking cognitive and emotional skills. Tools of Treatment: Teach children and adults how to work towards mutually satisfactory solutions to problems underlying difficult behavior. Emphasis: Proactive focus on solving and preventing problems before they occur. How Do These Children Get This Way? There are differing factors that may underlie the lack of skills with which they present. For some children it is purely developmental, for some it is more complex with neurological or neurobiochemical underpinnings as well. Dr. Greene and Dr. Ablon have identified 5 major pathways (Emotional/Cognitive Skill Areas) that if lacking frequently result in explosive behavior: The Five Major Pathways: Executive Function Skills Language Skills Emotional Regulation Skills Social Skills Cognitive Flexibility Skills EXECUTIVE SKILLS: These are the thinking skills, associated with the frontal lobe of the brain. They enable one to do the clear, organized, reflective thinking in the midst of frustration that is crucial for solving problems in an adaptive (non-impulsive) manner. The executive skills include: shifting cognitive set (the ability to shift gears, to make transitions in activities and thinking smoothly) organization and planning, and working memory (allow you to use hindsight and forethought to solve problems in a systematic fashion) separation of affect (the ability to put feelings on the shelf to get on with the clear thinking needed to solve problems) When lacking, these children will have difficulty shifting from one activity to another. They will have difficulty anticipating problems. In the face of frustration, they will have difficulty staying calm enough to think clearly and will have difficulty sorting through different solutions to organize a coherent plan of action. LANGUAGE SKILLS: Language skills are incredibly crucial as it relates to ones ability be flexible and deal with frustration. Problem solving is essentially a linguistic skill. Why? Most of the thinking and communicating that we do involves language. Language skills set the stage for labeling, categorizing, communicating and managing (metacognitive strategies) our emotions. They also kick-start problem solving by allowing us to label and communicate the problem, and do the necessary verbal give and take. Children with difficulty in this domain may gut hung up at any point. They may not have a rudimentary vocabulary for labeling their emotions (happy, sad, frustrated), may not be able to articulate their concerns (I am hungry/tired, I am in the middle of something) and may not have a problem solving vocabulary (I need help). When faced with frustration, or when trying to process situations later with the child, children lacking in this domain can often be heard saying such things as: shut-up, get away , I dont know, I dont want to talk about it or they may swear. EMOTION REGULATION SKILLS: This refers to the cognitive skills one uses to control, modulate and regulate emotions, outside of the context of frustration. It is important to note that this is different from separation of affect (our ability to put feelings aside so we can think clearly in the midst of frustration). What do we see with children who have difficulty in this domain: chronic grouchiness, irritability, fatigue, anxiety and agitation. These chronic states make dealing with frustration difficult. These children can often find the energy to look good in certain situations, only to fall apart later. COGNITIVE FLEXIBILITY SKILLS: Children who have difficulty in this area are wired in rigid, black and white ways. They are literal and concrete in their thinking and see things as their way or the highway. They often adhere to predictable routines/rigid/inflexible rules in order to feel ok. They become totally lost when things dont go just as they expected or the way they went the last time. Although they may be very bright verbally, they have poor skills when it comes to handling the grays of the world. Children who demonstrate these difficulties typically have great difficulty in the social arena. There is no area that requires the ability to see the gray more than social situations. SOCIAL SKILLS: There are two types of social skill deficits: cognitive deficiencies and cognitive distortions. What you will often see with cognitive deficiencies is poor perspective taking and appreciation of how ones behavior affects others, poor appreciation of social nuances, and poor social repertoires (ability to start a conversation, ability to enter a group). Cognitive distortions are typically based in reality, can often be seen as overgeneralizations or misconstruing of events. What Is Collaborative Problem Solving (CPS)? The Collaborative Problem Solving Approach (CPS), originated by Dr. Ross Greene, and described in his book The Explosive Child, is a practical alternative approach for helping behaviorally challenging children. One clue about how it is different from standard approaches lies in the word collaborative. Most standard approaches involve applying techniques (rewards and punishments) to these children. The word collaborative indicates that this approach is about utilizing new tools together with your child. The CPS approach is a tool for teaching lacking skills. Just as with a reading disability it will take time to make changes. The CPS Approach Is Based On Three Critical Points: THAT CHILDREN DO WELL IF THEY CAN These children are not choosing to be explosive and difficult. The outbursts are not intentional or planned, are not a way to manipulate adults or get attention. No child would want to feel this way. Listen to the child afterwards, and you will often hear how sorry he/she is for having lost control. Some children may have no recollection of what is was all about. Their outbursts are fueled by lagging thinking (cognitive) skills needed for coping with frustration. These children require a careful assessment to determine (a) the nature of their difficulties (pathways), (b) the factors that contribute to their overall level of frustration, and (c) the situations, times and people with which they have the most difficulty (triggers). They require an approach that is based upon a shared understanding of these difficulties. THAT YOUR EXPLANATION SHOULD GUIDE YOUR INTERVENTION If a lack of motivation is not the problem, then attempts to motivate these children to control their tempers (through rewards and punishments) makes little sense and may actually make things worse. Since a lack of skills is the problem, we need to create an environment and interventions that provide opportunities to help the child expand/catch up on their skills. These children respond best if they view adults as helpers who: understand their difficulties, recognize the need to establish parenting priorities, and are ready to help guide them through frustrating situations. THAT WE NEED TO FOCUS OUR EFFORTS ON THE FRONT-END We can provide the best help for these children if we focus our efforts before they become overwhelmed with frustration on solving and preventing problems rather than during or after a meltdown. The CPS Approach Has Three Goals: Allow adults to pursue expectations Teach lacking thinking (cognitive) skills Reduce meltdowns* *When a child enters into a meltdown they lose the ability to think clearly, no learning occurs. There is no evidence to indicate that having meltdowns will build lacking skills. Since motivation is not the key, and also that these kids typically lack the ability to remember the consequences of a prior event when in the midst of frustration, it is unlikely to be of help them to them in the future. The CPS Approach Has Three Ingredients: Understanding the pathways (skill deficits) underlying the explosive behavior, factors which add to overall level of frustration, and typical situations where meltdowns are most likely to occur (triggers-or problems yet to be solved) This may raise need for further assessments, and a comprehensive approach that includes CPS, as well as: medication, OT, social skills, organizational skills training, speech and language therapy. Decide what behaviors/expectations go into which Baskets. Use Front-end Mantra: Is this in Basket A, Basket B, or Basket C? Executing Basket B successfully so as to teach lacking skills. The Baskets Framework: There are and always have been only three ways for adults to resolve problems with kids. Adults can impose their will, let the child have his way, or work it out. The Baskets framework, renames these (Basket A,B,C,) and provides a method for establishing adult priorities, in other words it is a tool to help caregivers make decisions about how you wish to address problems or unmet expectations with the behaviorally challenging child. Basket A: (A=Adult) is when you impose your will. Your concern is the only one on the table. Basket A generally causes meltdowns. You know that you are in Basket A when what comes out of your mouth as you are entering the baskets is: No, You must, You cant, In five minutes you will, or 1-2-3, What you are likely to say after the baskets would be: He did what I said. Basket A helps adults ensure safety. Basket B: (B=Both) is the Collaborative Problem Solving basket. Basket B does not cause meltdowns. In Basket B, your role (at least initially) is as surrogate frontal lobe (doing what child cant yet do). You and the child are engaged in a process by which you will come up with mutually satisfactory solutions to problems (address triggers) or unmet expectations. Both your concern and the childs concern will be on the table. It is also Basket B, where you will help promote the communication and problem solving skills (address the pathways) that the child needs to be more flexible and handle frustrations more adaptively. You know you are in Basket B when what comes out of your mouth as you are entering the basket is: Lets work it out. After the Baskets, you are likely to say: We worked it out. Basket C: (C=Child) is where the adult is eliminating or reducing the problem expectation. Only the childs concern is considered. Basket C does not cause meltdowns. Basket C helps adults eliminate unnecessary demands, thereby reducing a childs global level of frustration and enabling him or her to deal more successfully with the more critical remaining demands. You know that you are in Basket C if nothing comes out of your mouth, except maybe: Okay or Oh. Later you might say: I didnt bring it up. It is important to note that the same problem can be handled in any of the baskets. Many adults rely on just Basket A and Basket C to resolve problems. Dr. Greene suggests that you will want to try and be in Basket B much of the time. If you are just using Baskets A and C you are really just picking your battles and missing an opportunity to help your child develop the lacking skills. Goals Achieved By Each Basket: Pursue Expectations Reduce Meltdowns Teach Skills BASKET A yes no no BASKET C no yes no BASKET B yes yes yes This chart emphasizes that adults can pursue their expectations in both Basket A and B. In other words, Basket B, just like Basket A is a limit-setting basket. The adult is not giving in, not saying yes, just wont be imposing their will. By engaging the child in Basket B, the adult will be letting the child know that their concerns are important, too and will be teaching lacking skills (the ability to identify and express concerns, the ability to take others concerns into account, the ability to generate possible solutions to create win-win situations) Implementing Basket B - The Three Steps: It is fairly simple to understand the Baskets Framework. However, it often takes caregivers time to learn how to execute Basket B, well and to feel comfortable doing it. Remember though, that unlike the effort involved in cleaning-up after a meltdown when doing Basket B you will have something to show for your effort. You will be helping the child in the long run, by building lacking skills. Basket B consists of three steps: Empathy (+Reassurance), Define the Problem, and Invitation. (Note: Dr. Greene and Ablon have changed the way they teach Basket B since the 2nd book publication was published. It was previously described as having two steps: (Empathy and Invitation). Empathy, which is communicated through reflective listening or the utterance of a simple, I hear you, accomplishes two missions: (1) it helps keep the child calm and (2) it ensures that the childs concern is on the table. If empathy is insufficient for keeping a child calm as youre initiating Basket B, it may be useful to add some reassurance (in other words, reassuring the child that youre not in Basket A). This is usually accomplished with a statement such as, Im not saying No. Often children will put their solution on the table rather than their concern (i.e.: I want pizza, rather than I am hungry). Getting the concern identified can often be accomplished with a statement, such as, Whats up. Problem Definition (Note: This step has been added since the book publication) is where the adult concern finds its way onto the table. The definition of a problem is simply a situation in which adult and child concerns have yet to be reconciled. Invitation is where youre inviting the child to work collaboratively toward a mutually satisfactory resolution of the two concerns (lets see if we can solve that problemlets work it out.) Thus, if a child were to verbalize, I dont want to go to bed right now, heres how the three steps of Basket B would sound: Empathy: You dont want to go to bed right now (note: this is a solution, not a concern). Whats Up? (need to identify concern). .Child responds: I want to watch the end of this t.v. show! (Reassurance): I am not saying you cant . Problem Definition: I am concerned about your getting up for school in the morning. Invitation: Lets think about how we can work that out. Give the child the first opportunity to propose a solution. If unable, you can then offer some possible solutions. What if the childs solution is not something you can agree with? Remember, solutions are supposed to be mutually satisfactory. Let the child know that her idea is a good one-but explain to him/her that it might make them happy, but wouldnt address your concern. Re-invite them to find a solution where everyones concerns are taken into account. What if the childs solution is not something you think they can realistically do at this point. Your job as surrogate frontal lobe is to guide them towards solutions that are within reach of their capabilities. You might say to the child: Wow that sounds like a great idea(shutting off the tv in 5 minutes), and I know that you would LIKE to be able to do that for me, but I have never seen you be able to do that before. Lets see if we can think of another way of solving the problem that is more doable. Proactive vs. Emergency Basket B: Dr. Greene now also differentiates between Emergency Basket B and Proactive Basket B. He has found that given a thorough understanding of the child (an essential aspect of the CPS approach) most meltdowns/explosions are highly predictable. By using Proactive Basket B, we can collaborate with the child to solve the problem when they are calm. What happens if when the time comes around the child forgets your previously agreed upon solution? You can always go back to Emergency Basket B. It may be that you agreed upon a solution that just wasnt doable (yet) by the child. Common Difficulties Executing Basket B: You may be waiting until things get heated up and then applying Emergency Basket B. In most families/classrooms, the same problems are causing meltdowns on a daily basis, which means these problems are highly predictable. Since the problems are predictable, youll be much better off trying to resolve them in Proactive Basket B, well before things get heated up. You must act as a surrogate lobe-weeding out solutions that wont work/child cant do yet. Even if child cant do what was agreed upon-in better place to do Basket B again-than if hadnt approached at all yet. You may not really be in Basket Bin fact, if a meltdown was the end result, theres an outstanding chance you were Basket A. Basket A with explanations-is still A. Time to go back and review the three entry steps for Basket B (empathy, define the problem, invitation) did you really use the three steps and in the correct order? If your child is accustomed to your being in Basket A, theres a good chance its going to take a while before they become accustomed to your being in Basket B. In other words, they may still get heated up in your early attempts to use Basket B because theyre just accustomed to getting heated up whenever is difficult problem is broached. Once they begin to trust that youre really doing things differently now, the calming effects of Basket B should take hold. Young children will typically need our help at least initially to generate possible solutions. It is important though that we remember though that it needs to be a collaborative process. Conclusion We hope is that you have a better sense of why it is crucial to understand the nature of a childs difficulties and why an approach aimed solely at motivation may not be well suited to these children. We hope that you begin to ask new questions as you think about these children. Instead of asking yourself, What is it going to take to motivate this child to behave differently? that instead you begin to ask, Why is this so hard for this child?, What s getting in his way?, How can I help? Resources Parents and Teachers of Explosive Kids: Provides education, resources and support for caregivers of children with behavioral challenges.  HYPERLINK "http://www.explosivekids.org" http://www.explosivekids.org Center for Collaborative Problem Solving: Includes information about the work of Dr. Ross Greene, including research, upcoming workshops, and the Collaborative Problem Solving Institute.  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