INTRODUCTION TO CHILDREN AT HIGH PSYCHOLOGICAL RISK
Hugh M. Leichtman, Ph.D. © 2000
Thirty years of therapeutic experience with 4000+ children at high psychological risk has provided me with understandings, observations and data-based information which I believe shed some light on this most heterogeneous and perplexing population. Initially, I think it helpful to look at children regarding age-appropriate development in the four major spheres of their functioning. These include the following common sense domains: the growth of the individual self, the child within the family, the child in relation to school and the I child in reference to his or her interpersonal community. Of primary concern in each of these spheres is the following: 1. How does the child's temperament play out? 2. What is the level of age-appropriate skill development? 3. What is the level of performance in relation to the child's established base of mastery? and 4. What are the variables impeding learning? This " first take" on a child is a rough cut documentation of age-appropriate competency and adaptive capacity. ~ What do we usually find with this broad review? First and foremost we see that these children characteristically show developmental lags of 1-2 years in at least two spheres of functioning by age seven. By the chronological age of nine or ten, these lags have frequently grown to include three to four spheres and skill deficits now appear cumulative in nature. I When these initial findings are followed up by a well structured developmentally based history, several phenomena literally jump out at you. In no particular order you find the presence of possible fetal drug effects, chronically chaotic parenting, maltreatment, and executive function.
Consider that our population of children at high psychological risk is a crazy quilt of patches compromising no less than 6% of the nation's children and youth. This quilt is elaborated upon annually by a minimum of a million documented child abuse/neglect cases backed up by an extraordinary number of unsubstantiated maltreatment cases. Add to this the growing incidence rates of Pervasive Developmental Delays and the impressive ADD/executive function deficit statistics and you begin to grasp the sheer size of the problem. Its very magnitude makes almost humorous the band aids brought forth such as fast track adoption, massive doses of Ritalin, short-term family strengthening programs which cannot even begin to remedy paramount issues each as developmental stabilization and placement in inclusive classroom settings where the child's opportunities for success are often minimized.
The bottom line to these statistics is the not so well kept secret that only 40% of these youngsters are unlikely to graduate from high school. And then what? What is in the cards for those without high school diplomas? And then what is in store for those who will graduate, but are weighted down by such a tower of risks that they are prone to break down under the most normative of stressors. The good news about children at high psychological risk is that most of their lives can be reclaimed, stabilized and oriented toward skill acquisition and productivity IF given the appropriate service and educational plans that are driven by their diagnostic profiles.
Do not believe that even under the weight of multiple risks (say 50-60 or more primary, secondary and third order risks) that these children cannot move on in their lives. Given the right conditions, these children will grow and grow substantially. Many will require polypharmacy, all will require family work and all must have educational settings with the capacity to meet the multiplicity of their needs.
Since these children's developmental trajectories are offline, only a unified service model consistently delivered over time will produce documental results. And interestingly the results will not so much be found in symptomatic change except for that authorized by medication. No, positive result will be observed in the development of new adaptive capacities, new problem solving abilities, new social skills, new cognitive frameworks that will actually compete with the old fragmented internal guidance systems established earlier in life.
To pull this off we must have families allied with clinicians trained to build increasingly effective child rearing practices and relatively stable home environments. This requires a strength based model that is always in the business of containing ingrained familial symptoms and the family's propensity for crisis. Effective family work is additive. It brings new resources, new problem solving capacities to families whose resources are outstripped by the demands of their high-risk children. Effective family work always shows the way for substance dependent parents to get appropriate treatment for this approach recognizes that the best therapeutic intervention is rendered impotent if drug/alcohol related difficulties are not openly addressed.
Effective family work is never confused by the old axiom that children's symptoms are a reflection of family dynamics, yet it goes without saying that a child's symptoms are typically inflamed by an outbreak of inappropriate family functioning. Effective family intervention pushes the psychological envelope of understanding by noting that children at high psychological risk can and do disturb fragile family systems as well as reasonably functioning parents. This explains the need for scheduled (note not crisis) respite care that is voiced by so many families. Such family work also recognizes that the fragmented histories of children in foster or adoptive situations will repetitively cycle in their substitute families and that specialized post adoptive (foster) care may well determine the child's overall outcome.
Not enough can be said about the extraordinary importance of finding a school setting that meets the needs of this population. Without appropriate protection, facilitation and curricula, these children will only add to their already abundant failure histories even though overt symptoms such as hyperactivity and broken attentional streams will often have been moderated by stimulated medications.
And then comes perhaps the toughest nut to crack: how do these children acquire the social skills absent from their behavioral repertoires? Let me say straight that our once-a-week ~ skill building groups that many schools offer is nothing more than a mirage.
No, what is needed is access to therapeutic programming on a year-round basis that offers skill building activities so intrinsically attractive that these typically avoidant children cannot resist becoming involved. It is through countless repetitions (thousand upon thousands) that a new skill foundation is developed which serves as a scaffold for developing the next order of age-appropriate capacities.
And another question: Can these children make use of individual psychotherapy? I think that this is largely dependent on the child's level of intellectual functioning. That said, I think therapy can play a most important role in 1. Helping the child learn how to process events accurately, 2. Can help the child understand how his/her brain works, 3. Can help the child, over time, construct his life story which is absolutely critical for maltreated children, 4. Using a variety of materials can help children understand the realities of their families and their particular role within the family structure, 5. Can constructively work on self-regulation issues of choices and consequences and 6. Can help the child recognize and expand their experience of their emotional signals and the contexts in which they occur.
To bring these children's developmental trajectories back to those approaching their more normal counterparts requires a huge investment in money, time and expertise. There is no easy way as the rising rate of failed adoptions and school dropouts will attest.
But a good percentage (something in the 75-80% range I would estimate) of these lives at high risk can be stabilized and reclaimed. It's all a matter of will. Will we invest in this population sufficiently to allow their development to become realigned and proceed on its way towards age-appropriate productivity?