Putting the Bounce Back in Their Step: Promoting Resilience in Children at
High Psychological Risk
Harvey I. Botman, Ph.D. and Hugh M. Leichtman, Ph.D., ©2001
At Wediko Children's Services, we have developed multi-modal therapeutic intervention strategies for working with children and adolescents showing significant emotional and behavioral disturbance. The typical youngster referred to Wediko has become increasingly dysfunctional at home, at school, and in the community. Characteristically, students arrive at Wediko with impressive files chronicling a sad and often turbulent life replete with difficult temperament, traumatic experiences, biologically-based traits which are problematic, learning disabilities, psychiatric diagnoses, psychoactive medications, counseling and special educational placements.
We work with children and adolescents who have struggled against overwhelming odds. They have risk factor pancaked upon risk factor. Many are suspected of having fetal drug effects, or shadow forms of mental illness. Almost all are burdened with significant neuropsychological deficits frequently presenting a smorgasbord of disorders including: attention, memory, sequential processing, simultaneous processing, sensory-motor functioning, language, thinking, mood, anxiety, and relatedness. Often their personal histories are replete with accounts of diminished self-regulation capacities, poorly integrated affect, disinhibited actions, and bouts of disorganized cognition. Moreover, this panoply of discrete and overlapping conditions has typically been minimized in comparison to the striking behavioral/emotional symptoms that have forced increasingly restrictive educational placement upon these students. Invariably, causality of Resilience and Risk their maladjustment is singularly attributed to storms of relentless family stress often highlighted by neglect, emotional abuse, exposure to harm, school failure, and peer rejection.
At Wediko, our work with children and adolescents begins with in-depth evaluation. At the initial stage of assessment, we go about the process of determining the goodness of fit between our therapeutic/educational methodology and the characteristics of the referred child. By the first interview, we have systematically scoured the child's educational, mental health, and medical records for data regarding key elements of the child's developmental, educational and social history. Concomitantly, we review the responses to our own questionnaires from the child's family, school and clinicians regarding current adjustment. Structured interviews are then conducted with the student and his family to assess family patterns and resources. We combine this information with data drawn from Wediko's risk/off-setting factor inventories to develop a comprehensive working formulation. This formulation will assist in the admission decision will help structure the initial educational and treatment approaches after acceptance into Wediko.
When we plan for our students, we consider how specific therapeutic approaches might contain risk factors and while others might strengthen off-setting (protective) processes such as enhanced self-management, capacity for relationship and increased achievement in a targeted learning domain. We consider how some risk factors (e.g., learning disabilities and exposure to harm) are conditions that the student will have to compensate for and contend with throughout life, while others (e.g., ineffectual parental parenting techniques and a lack of reading skill) are conditions that can be directly ameliorated during their Wediko stay.
Among the therapeutic resources critical to students' progress at Wediko are integrated psychiatric care, individualized academics, extensive interpersonal supports, milieu-wide behavior management practices, family therapy, comprehensive activity programming, and
intensive psychotherapy when indicated. These therapeutic resources are coordinated and attuned for each student so as to optimize adaptive coping and promote euthymic experience. Critical to this end is the data we collect through on-going observation, in-depth educational assessment, and comprehensive neuropsychological evaluation. This pooled data enables us to periodically revise treatment/educational approaches and plan distinct courses of action to help students maximize their competencies and build new skills which will gradually offset their maladaptive styles of functioning.
Essential to Wediko's therapeutic work is the acquisition of competencies associated with resiliency. This pursuit begins with an identification of the off-setting factors that each student brings to the setting. We specifically identify assets in the neuropsychological realm, the intrapsychic realm, the interpersonal realm, and the production-or-task realm. These assets serve as the psychological firmarment upon which we work with students to build increasingly effective capacities for adaptive functioning. However, we understand that this bedrock assumption will be eroded, perhaps undermined completely, if the child's symptoms are not effectively managed and contained.
Our understanding of the association between off-setting or protective factors and resilience is derived from our close study of the literature (e.g.: Garmezy & Rutter, 1983; Haggerty et al., j 1994; Henderson & Milstein, 1996; Hetherington & Blechman, 1996; Joseph, 1994; Katz, 1997; Mastin et al., 1991; Rutter, 1985; Weissbourd, 1996; Werner & Smith, 1992; Wertlieb et al., 1987) and a combined fifty years of experience working with high risk children. Because we see resilience as an emergent phenomenon arising from the confluence of individual factors, family factors, and environmental factors, we see building resilience as the essential goal of all of our therapeutic and educational efforts. Towards this end we focus our energies on the strengthening and developing of protective factors that will serve to offset the deleterious effects that certain risk factors have on resiliency. To promote this goal of enhanced adaptive capability for each student, we identify which aspects of Wediko's therapeutic milieu will be seminal to the development of critical competencies, self-esteem, and relatedness. Thus, we attempt to arrange both the human and the structural dimensions of those aspects of the milieu so that students will be "off and running" towards their individualized goals which will eventually lead to more resilient functioning.
Simultaneously, we strive to minimize the insidious effects of the risk factors of our vulnerable children. We address those that involve psychiatric issues with psychoactive medications; those that involve academic deficits with direct instruction. For those issues that derive from neuropsychological disabilities we will prescribe of cognitive strategies and environmental modifications, and those that involve self-deregulation and maladaptive socialization with milieu support, cognitive behavioral interventions, and social skills training.
Two brief clinical vignettes follow to illustrate how we promote protective factors and minimize risk factors in our work with children and adolescents at Wediko.
Gerald was a physically large, bi-racial, ten-year-old boy who came to Wediko when his single mother and home school concluded they no longer could contend with his steady barrage of hurtful words and aggressive behaviors. He had been an overly-active, hard-to-soothe baby who became a moody, irascible toddler. In first grade, his emotional outbursts at school led him to be placed in a self-contained class. He then required psychiatric hospitalization and was prescribed a number of psychoactive mediations, all without lasting beneficial effects. Placement at Wediko had become a last resort.
Our initial assessments of Gerald found a boy whose risk factors swamped his protective factors as is invariably the case with children this volatile. Among his risk factors, were noted dyslexia that would be amenable to an individualized phonics-based reading program and subtle expressive language deficits that would be amenable to speech-and-language therapy. His proclivity towards becoming over stimulated and hyper-aggressive was managed by placement in a living group with fewer children where a highly structured adaptive living skills approach used with our more fragile children was being implemented. Among his protective factors, we noted strong artistic interests and talents that could serve as the basis for a sense of self efficacy and a history of approach-and-avoidance toward adult males that might appropriately channeled if he could anchored in a relationship with a certain type of male.
Outcomes: Gerald has shown significant progress in developing stress tolerance, self-control and interpersonal connection. Episodes of paranoid driven aggression have declined substantially. Academic achievement is picking up speed and planning is now underway to transition Gerald back to public school for the new school year. Additionally Gerald appears increasingly intelligent and verbally articulate with his new found capacities for age-appropriate verbal expression and self-control.
Yuri was a wiry fifteen-year-old boy who came to us when his adoptive mother felt she could no longer maintain the physical and psychological safety of her home whenever he was present.
According to Yuri's sketchy pediatric records, both of his birth parents had been alcoholics; his birth mother had abandoned the family; and his birth father had been killed in a late night assault by one of birth mother's lovers. Yuri and his sisters had been adopted after a two-year stay in a Russian orphanage. They had been in this country for almost three years when Yuri was accepted at Wediko. Initial assessments of Yuri identified almost four times as many risk factors as protective factors, not an uncommon finding. Central among his risk factors was a mild nonverbal learning disability which could be contained by reducing ambiguities and relying on explicit verbal messages when interacting with him. Among his protective factors were his responsiveness to structure which could be utilized to ground him in Wediko's behavior management system and his strong autonomy strivings which could be mobilized to propel achievement in certain academic subjects at and in after-school activities. Furthermore, to promote Yuri's successful treatment at Wediko, it was imperative to contain the risk factors that pertained to Yuri's mistrustfulness by depersonalizing interpersonal demands (i.e., presenting them as "the way it should be done'') and reducing demands for self-disclosure (i.e., moving from to talking about feelings and motivations to talking about facts).
Outcomes: Yuri's competency gains have been remarkable in terms of self-knowledge, gratification from achievement and a growing capacity to make constructive personal decisions. He has become actively involved in sports and shows a blooming interest in almost anything athletic. His problem solving skills are developing nicely. Grade level academic achievement is consistent and he is able to hold a part-time job outside of the setting. He will be transitioned out of Wediko even though capacity for in-depth reciprocal relationship remains curtailed.
Two years later and a senior in high school, Yuri is performing at grade level, has his driver's license and is helping his mother with their small family farm. Though his mother states that Yuri is far from being immediately complaint, he is able to cooperate and negotiate. "You can reason things through with him even though it may take several repetitions. That's something he could never do before."