ASSUMPTIONS REGARDING CHILDREN AT HIGH PSYCHOLOGICAL RISK
Hugh M. Leichtman, Ph.D. © 2000
1. The complex functioning of children at high psychological risk should always be viewed from a ecological perspective.
2. Through experience, child brains are shaped and streamlined to meet environmental stimulation and demands for adaptation.
3. Children are naturally resilient ("they can take a licking and keep on ticking.") Assume that seriously troubled children are not resilient indicating the interference of multiple risk variables interfering with their adaptive capabilities. Such interference will undermine the consistent acquisition of internal guidance systems, essential skills and developing competence's. Further assume that the interaction of multiple risk factors will have substantial impact on the child's developing self-system.
4. Assume the children at high psychological risk are intrically complicated and require extensive multidisciplinary evaluation including comprehensive neuropsychological assessment to provide the most accurate diagnostic picture possible. This diagnostic picture should inform and shape the child's service and educational plan.
5. Note that all risk features are not created equal with certain risks acting as magnifying factors on existing vulnerabilities: a. Prenatal factors (e.g., exposure to drugs, malnutrition) b. Postnatal factors (e.g., head injuries) c. Temperament problems not offset by facilitating parenting d. Executive function deficits interacting with learning weaknesses and learning disabilities e. Biologically based psychiatric conditions including pervasive developmental delays and j childhood onset of mental illness such as bi-polar disorders ~ f. Relatively persistent chaotic family circumstances g. Exposure to gross maltreatment including repetitive physical and sexual abuse h. Exposure to neglect, verbal abuse and parental rejection
i. Witnessing the maltreatment of others (e.g., abuse of the primary parent)
j. Exposure to deviant, often violently oriented social groupings such as gangs. !
6. Assume that family functioning is likely to become increasingly unstable when a child's symptoms exceed family resources.
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~) ASSUMPTIONS REGARDING CHILDREN AT HIGH PSYCHOLOGICAL RISK
1. The complex functioning of children at high psychological risk should always be viewed from a ecological perspective.
2. Through experience, child brains are shaped and streamlined to meet environmental
stimulation and demands for adaptation.
3. Children are naturally resilient ("they can take a licking and keep on ticking.") Assume that seriously troubled children are not resilient indicating the interference of multiple risk variables interfering with their adaptive capabilities. Such interference will undermine the consistent acquisition of internal guidance systems, essential skills and developing competen~es. Further assume that the interaction of multiple risk factors will have substantial impact on the child's developing self-system. .` .
4. Assume the children at high psychological risk are intrically complicated and require extensive multidisciplinary evaluation including comprehensive neuropsychological assessment to provide the most accurate diagnostic picture possible. This diagnostic picture should inform and shape the child's service and educational plan.
5. Note that all risk features are not created equal with certain risks acting as magnifying factors on existing vulnerabilities: a. Prenatal factors (e.g., exposure to drugs, malnutrition) b. Postnatal factors (e.g., head injuries) c. Temperament problems not offset by facilitating parenting d. Executive function def~cits interacting with learning weaknesses and learning disabilities e. Biologically based psychiatric conditions including pervasive developmental delays and childhood onset of mental illness such as bi-polar disorders f. Relatively persistent chaotic family circumstances g. Exposure to gross maltreatment including repetitive physical and sexual abuse h. Exposure to neglect, verbal abuse and parental rejection i. Witnessing the maltreatment of others (e.g., abuse of the primary parent) j. Exposure to deviant, often violently oriented social groupings such as gangs.
6. Assume that family functioning is likely to become increasingly unstable when a child's symptoms exceed family resources.
7. Expect that certain subgroups of children due to temperament difficulties, executive function impairments and pervasive developmental delay symptoms have a much higher probability of being physically and emotionally maltreated than their "normal" counterparts.
8. The earliest form of intervention possible will serve as damage control as long as a protective, developmentally facilitating environment surrounding the child will immediately follow.
9. Quick in and out family stabilization practices often do not provide the necessary therapeutic input for longer-term family reorganization even though rapid changes in parental behavior may initially appear.
10. Assume that strengths exist in many disorganized families that can be identified, effectively coached and built upon so that parenting practices become increasingly effective. Also assume that substantial time will have to be invested in forming relationships which will serve as the foundation for this therapeutic work.
11. Assume that even with the significant number of detached and maltreating parents that most parents regardless of their child rearing capabilities love their children and want the best for them. The pivotal issue is how to build a nurturing, consistent environment where follow-through is the key regarding facilitating child rearing practices.
12. Removing a child from exposure to at-risk situations of neglect and/or maltreatment in no way suggests that the child's development is then risk free. Residuals from trauma exposure should be expected, the scope and permanency of which will be determined by intensity, duration and comprehensiveness of exposure, identity of the perpetrator, constitutional factors such as temperament and intelligence, presence or absence of learning disabilities, developmental age and other offsetting factors.
13. High risk children often show an exaggerated sense of attachment to their maltreating biological families. Assume highly intermittent, unreliable availability of basic resources as a contributing cause of this heightened and often brittle connection. Understand that these children love their neglectful and/or abusing parents, rationalize away their parents' functioning and typically idealize them regardless of the harm experienced.
14. For children living in chaotic or abusing familial situations, the probability of parental involvement with alcohol or other substances is high. Therefore ongoing alcohol or substance abuse should be ruled in or out for each family. Assume that family work without acknowledgment of parental drug involvement, when present, perpetuates family volatility and silently colludes with drug usage.
15. Expect that children coming from chaotic family circumstances will have behavioral repertoires reflective of their home situations. Assume thousands of corrective inputs will be required to build social skill repertoires which will compete with the family driven repertoires.
16. Assume dysregulated brain stem activity for many (but certainly not all) maltreated children which is characteristically associated with a perpetually high state of emotional arousal.
17. Assume that children exposed to maltreatment who do not show Post-Traumatic stress symptoms are neurologically intact and resilient. Assume that solid intelligence, easy temperament, a marked area of success and at least one stable, affirming adult relationship contribute to this observed resiliency.
18. Assume that with certain subgroups of traumatized children, driving needs push them to repeat their traumatizing experiences.
19. For a child who has been repeatedly harmed by a particular family member, that individual often becomes a conditioned stimulus who can activate post traumatic stress symptoms in the child.
20. Assume that exposure to repetitive verbal abuse, particularly when accompanied by explosive parenting, may damage the child's self system in a fashion more devastating in terms of lasting impact, than limited incidents of physical or sexual abuse.
21. Quite possibly, parental rejection leaves a lasting affective/cognitive imprint where the high-risk child feels responsible for the rejection and never feels "good enough".
22. Assume that many families of highly symptomatic children are functional, are doing their absolute best for their children and love them dearly. Further assume that family symptoms in these cases are often stress related and are caused by their children's neurologically based symptoms, particularly seen with major executive function problems, pervasive developmental delays and mental illness. This is often observed in foster and adoptive situations as well as biological families.
23. Many children removed from their biological families are never given permission to leave. Additionally, it is a common occurrence for these children to misunderstand termination of parental rights. This lack of clarity fuels loyalty bonds and actively interferes with connections to a new family.
24. Older children (children five years and older) when removed from their families of origin tend to remain forever loyal to those families. Therefore expect conflicted loyalties to be played out for years to come which will require extensive post adoptive services.
25. As a rule of thumb, most high-risk children do not have an accurate cognitive framework for understanding their family context and personal situation. Typically, they have sparse comprehension of their internal turmoil, their negative outlook on life, their inability to profit from experience and how their brain works when executive function difficulties exist.
26. Many seriously troubled children have significant difficulty with social comprehension and the accurate processing of their own behavior. Often these children give the appearance of not being able to think through social situations.
27. It is a common occurrence for seriously troubled children to function quite differently from one context to another. This variance is often seen between home and school environments. Many adopted children at high risk will thrive in school while having major conflicts at home. Parents of children from chaotic families frequently report never seeing the deviant behavior reported by the school.
28. High risk adolescents are expert at secreting large segments of their lives away from their parents which dramatically increases their developmental risk.
29. Assume that the majority of seriously troubled children cannot accurately tell their life story. This inability prevents them from developing a coherent and detailed explanation of their life situation and perpetuates their propensity towards self-punitiveness and family idealization.
30. When reaching adolescence, many multiple problem children have experienced such an extensive history of failure that they have little sense of purpose and a limited sense of the future. This orientation predisposes them towards stimulus seeking and living in the "now" where consequences for actions seem irrelevant.
31. For multiple problem adolescents living in urban areas, street time and association with street culture should, perhaps, be considered one of the greatest threats to long-term development
32. Negative developmental outcome increases exponentially when children disengage from their emotional connections with their parents and forge primary loyalty bonds with their similarly alienated peers.
33. Long term child/parental conflict fueled by a child's negativity and defiance often leads to parental withdrawal and a child with ingrained difficulties with anger management, impulse control and needs for dominance.
34. Seriously troubled children tend not to view their functioning as do their mothers and teachers. Such distortions in self-observation impede accurate processing of feedback. If distorted self-observation remains uncorrected, the child's sense of victimization may become increasingly crystallized, evolve into a paranoid adjustment style which in turn justifies violence in relation to perceived threat.
35. High risk children are inclined to present themselves as disconnected from their functioning. Though seeing, quite exquisitely, the impact of others' behavior on them, they are often blind to the impact of their behavior on others. This sensitization to others' threat potential often serves to release aggressive acting out.
36. It is a gross mistake to assume that all high risk children have been exposed to maltreatment. Childhood onset of mental illness or pervasive developmental delays including Aspergers Syndrome and multiplex developmental problems may actually prove more significant risk factors associated with developmental failure than maltreatment.
37. Children who are isolated and/or scapegoated will characteristically find refuge in fantasy or some solitary activity. If given the opportunity, loners will pair up and engage in activity that reduces their sense of alienation and powerlessness, sometimes to the detriment of their personal development and that of others particularly if they have access to weapons.
38. Assume that growing children have an intrinsic need to define themselves as effective and capable. Further assume that reading deficits and/or other academic shortcomings leave children with a vacuum regarding their sense of competency and their ability to have impact in their immediate environment. Finally assume that this vacuum is often filled with negativity, defiance and aggression which not only provides biochemical comfort, but a sense of power and control.
39. Each child considered at high psychological risk should be regarded as unique concerning his/her profile of risk and offsetting (strengths) features.
40. Children at high psychological risk are typically idiosyncratic learners.
41. Variability in academic performance is assumed for children at high psychological risk. This inconsistency reflects an uneven profile of intellectual strengths burdened by attentional difficulties and other executive function deficits.
42. The common belief that children's behavioral symptoms are functional is patently untrue. This false notion persistently positions teachers and allied professionals to construe maladaptive functioning as being motivationally based instead of being based on neurological or skill deficits. Sound formal and observational assessment allows for demarcation between symptoms which have functional value and those which do not.
43. Seriously troubled children are prone to over stimulation which leads to emotional activation followed by outbreaks of symptomatic behavior.
44. In serious emotional disturbance, symptoms should be considered as barriers to developing age-appropriate competencies. Strategies for symptom containment must therefore be developed in parallel with strategies aimed at developing interests and age-appropriate skills. Strength based strategies alone will have marginal success if symptoms are not contained.
45. High risk children often possess consistent or signature patterns for managing emotional arousal, perceived conflict or status challenge. These patterns when left unchecked will typically be expressed in full blown symptomatic behavior. Such maladaptive expressions can be avoided or lessened by intervening early in the onset of a signature behavioral cycle.
46. Children who are seriously troubled bear such an unstable tower of risks that when this risk structure breaks down for any reason, deterioration in adaptive -capability is seen immediately. Such behavioral deterioration is noted during moments of over stimulation and during simple transitions such as moving from one part of a schedule to another. Major transitions such as moving from one developmental era to another are primary times when risks often overwhelm strengths and periods of decompensation, often extended, occur.
47. Children at high risk are often late bloomers in terms of their moral, social and academic development. This is due to risk variables which interfere with the complete and timely acquisition of age appropriate adaptive capabilities such as exploration, sharing, cooperation and motivation towards new learning.
48. Seriously disturbed children are characteristically caught in negative feedback webs which induce states of learned helplessness. To break through this sense of discouragement requires active encouragement, support and the repeated experience of success only provided by a comprehensive, facilitating, high interest, skill building program. Once the child begins to define himself/herself as successful, a sense of courage begins to emerge which purposefully motivates attempts at riew learning.
49. For children who find no exit from entangling negative feedback webs, the resulting symptomology will often include dysthymia, self-punitive behavior and periodic acts of defiance, aggression and stimulus seeking.
50. For seriously disturbed children to move forward in their social development, gratification from age-appropriate fun and achievement must compete with the pleasure associated with impulsivity, power based behavior and specific forms of odd functioning.
51. Never underestimate the function of aggression and unpredictable impulsivity to meet the high risk child's needs for control, power, tension release and self-esteem.
52. Aggressive, more coercively prone children and youth appear to hunger for stimulation that feeds their aggressive inclinations such as "gangsta" rap music, violent video games and movies lade with violence and gore. At times it is helpful to view coercive behavior from the perspective of an addiction model.
53. Social outliers whether it associated with ADHD, Asperge's, bi-polar disorders etc., by definition have restricted opportunities to develop age-appropriate social skills and guiding moral standards. So as their chronological age advances, they become increasingly isolated as their social skill deficiencies reach critical mass and typically find themselves out of sync with their peers.
54. Children with social connection deficits develop compensatory interpersonal skills in the context of intimacy, repetitive interactive individual relationships and therapeutic social groups. The key to this compensatory social learning is repetitive experience which gradually becomes internalized.
55. Children at high risk often lack neurological integration which is directly reflected in unpredictable functioning. The assumption is that the greater the repetition of specific constructive experience, the greater the neural integration since new neural connections are being formed. The proverbial two steps forward, one step back, four steps forward, three steps back suggests that there has been insufficient repetition to produce the new levels of neural connection necessary to support the new level of adaptive capability.
56. Symptoms should be assumed to have a neurological base before a psychological formulation is made. In children at high risk, many symptoms are neurologically based and fused with a well-developed psychological overlay. A matrix of causal factors is assumed when attempt to understand the etiology of high-risk symptoms. To be sure, there are clearly instances when children are neurologically intact and symptoms are psychologically based such as exposure to chaotic family conditions, verbal abuse and other forms of maltreatment. However, when maltreatment continues, permanent brain alterations may follow.
57. With an exceptionally high rate of frequency, children at high psychological risk are under diagnosed regarding A.) fetal drug effects, B.) learning disabilities with particular emphasis on nonverbal learning disorders and C.) subtle though disorders.
58. Assume that sensory input systems of children at high risk often vary in their responsiveness to immediate environmental information.
59. Medication, as a rule, is deemed an essential treatment component for many seriously disturbed children. Polypharmacy is often required to target multiple symptoms.
60. Even when medications are effective at dissipating symptoms, a void of appropriate social skills and coping mechanisms remains which often slows positive development momentum.
61. Many high risk students show altered sensory thresholds, which in turn distort their sense of reality. For such children occupational therapy interventions become a primary component of the educational plan.
62. Assume the existence of expressive communication, language and reading problems in the seriously disturbed population. Determine presence through appropriate language, reading and neuropsychological testing. Speech and language therapists and reading specialists should be added to the team as indicated.
63. Assume the presence of sensory motor, gross motor or fine motor difficulties in children at high psychological risk. Determine motor deficits through neuropsychological assessment; add adaptive PE and protected recreational activities to the IEP when indicated.
64. Assume that these children will show a restricted affective continuum across a broad range of affective experience. Such a narrowing of affective signals curtails judgment, choice making and significantly impairs adaptation. Developing treatment interventions which gradually expand gradations of affective experience and then makes connections between recognized affective signals and certain behavioral acts is essential. -'
65. The continuum of least restrictive to most restrictive environment should be redefined by the level of academic and social achievement associated with a particular educational environment. Accordingly, a mainstreamed, least restrictive academic setting can, in fact, restrict achievement opportunities because the setting does not meet goodness of fit requirements (i.e. The match between the child's needs and the setting's expectations). On such occasions, the least restrictive environment is transformed into one that is highly restrictive since it restricts success. Paradoxically, a more restrictive environment which protects and facilitates a child's achievement and growth can be viewed as less restrictive since it is associated with increased academic and social gain.
66. Assume that these risky children have not found a niche where they experience themselves as successful. Often that niche is found outside formal schooling and is centered on interests and skills which may hot be school related.
67. Token systems, star charts and sticker systems soon lose their effectiveness to shape specific behaviors without the leverage of strong, meaningful interpersonal relationships. Even with the presence of high valence personal connections, reward systems tend to satiate rather quickly unless frequently revised and freshened.
68. Because of symptom chronicity associated with children at high psychological risk, behavioral change cannot be accurately measured through symptom reduction. Instead, the growth of new competencies should be the target measured to determine responsiveness to particular therapeutic protocols.
69. Assume that developmental trajectories can be realigned and become increasingly adaptive and successful. This happens when facilitating social connections, accompanied by academic and comprehensive experiential learning curricula meet individualized goodness-of-fit requirements and are complemented by effective multi-modality treatments over time.
70. Life turning growth can be documented when children begin to define themselves as learners and not by their symptoms.