Building Resiliency in Kids

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1 BRiK Building Resiliency in Kids INSTITUTE FOR HEALTH & RECOVERY

2 Acknowledgments The original source of this curriculum was Einat Peled and Diane Davis (1995) Groupwork with Children of Battered Women: A Practitioner s Manual, Thousand Oaks, Calif: SAGE Publications. Significant adaptations, with approval from original authors, were made under a study (and adaptation of the manual contained herein), funded under Guidance for Applicants (GFA) No. TI entitled Cooperative Agreement to Study Children of Women with Alcohol, Drug Abuse and Mental Health (ADM) Disorders Who Have Histories of Violence from the Department of Health and Human Services, Public Health Service, and Substance use and Mental Health Services Administration s three centers: Center for Substance use Treatment, Center for Mental Health Services, and Center for Substance use Prevention (March 2000). Later adaptations and revisions were made by staff at the Institute for Health & Recovery with funding from the Greater Boston Council on Alcoholism and the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. iii

3 Contents Part I 1 Introduction Part II 7 Session Structure Part III 13 Group Sessions Getting to Know Each Other What Hands Can Do Anger Substance Use Sharing Personal Experiences with Violence Touch Being Strong Safety Planning Review and Good-Bye Appendix 41 Resources 45 Safety Plan

4 Part 1 Introduction This program is designed for children in families affected by substance use, mental illness and domestic violence. The major goals are: To support children s own vocabulary of feelings To strengthen children s self-esteem To promote resiliency To break the secret of abuse in the family To help children learn skills to protect themselves This group program has nine core group sessions for children. It includes guidance for orientation of parents, individually or in a group, to help parents support their children in the program. Each session focuses on one theme or message, with stated desired outcomes for participants. Session structure is consistent an important factor for children. This consistent structure is described in part two. Orientation for parents and the specifics of each session for children are described in part three. The appendix includes a listing of recommended books and videos that might be used in this program, or other similar programs. Background This program is a result of a unique intervention for children of mothers with co-occurring disorders and histories of violence. The intervention was designed and implemented by the Institute for Health and Recovery as part of the US Department of Health and Human Services, Substance use and Mental Health Services Administration s Women, Co-occurring Disorders and Violence-Children s Subset Study (WCDV-CSS). Children exposed to parental substance use are at increased risk for many problems including: emotional and behavioral disorders; poor developmental outcomes; conduct disorder; abuse of alcohol and other drugs; and physical abuse, sexual abuse, and neglect. When violence and parental mental illness also occur, children suffer emotionally, socially, behaviorally, intellectually and physically. The children s group component of the WCDV-CSS that this volume is based on was an adaptation of Groupwork with Children of Battered Women: A Practitioner s Manual, by Einet Peled and Diane Davis, The goals of the children s group intervention were to develop coping skills related to improving self-protection, vocabulary of emotions, and self-esteem. Initial modifications were made to respond to the constellation of substance use, violence and mental 1

5 illness, as well as the integrated services of the intervention. The importance of service integration is a key finding of the initial intervention.1 Following conclusion of the original studies, the authors continued to adapt and refine the children s program, supported by a grant from the Greater Boston Council on Alcoholism. The program presented here represents the outcome of this multiphased study and testing. Target Population This program is designed for children and families who have experienced a constellation of troubles: substance use, mental illness and violence. As a result of witnessing parents turmoil and, too often, experiencing harm, children often develop their own constellation of behavioral, emotional, mental and developmental challenges. Children may believe they are at fault for their parents troubles; they experience profound conflict over their own inability to protect parents or siblings, and over the failures of parents to protect the children from harm. Children may have acted with great maturity and savvy in caring for younger siblings, and may resent being treated like a child. Many children are afflicted by impulsive or explosive outbursts, which frighten themselves as well as others. Other children may become withdrawn or tuned out and challenging to engage. Bringing together a group of children with these experiences, and successfully engaging their parents can be a daunting task: one that should not be undertaken without adequate support and resources. The following section describes some of the essentials. Essentials for Successful Implementation 1. Integrated services and care coordination This program is intended to be offered in an agency, or a cooperative effort of agencies, providing integrated services for all family members. All participating sites in the original study offered treatment for co-occurring disorders, as well as parenting services and children s services. The original intervention demonstrated the importance of: 1. Treating the family as a system of interdependent members 2. Creating a safe, nurturing and consistent treatment environment 1. For results of this implementation, see: N. R. VanDerMark, et al. (2005) Children of mothers with histories of substance use, mental illness and trauma. Journal of Community Psychology, 33, ; N. Finkelstein, et al. (2005) Building resilience in children of mothers who have co-occurring disorders and histories of violence. Journal of Behavioral Health Services & Research, 32, ; C. D. Noether, et al. (2007) Promoting resilience in children of mothers with co-occurring disorders and histories of trauma. Journal of Community Psychology, 35,

6 3. Modeling appropriate interpersonal behaviors 4. Building skills in self-care, coping, safety, and interpersonal communication To address these issues, the cross-site intervention consisted of three components: 1. Clinical assessment of the child 2. Service coordination and advocacy 3. A developmentally matched skills building group The ideal setting for the children s program is one in which parents and children s services are located under one agency, in one place. However, services may be offered under different auspices as long as care coordination is well established and consistent. For example, clinical services for parents provided in a treatment setting (outpatient or residential) while the program for children is provided in a day care setting. However services are configured, communication and coordination among service providers is essential. Facilitators for children s groups should meet with and get to know parents, and be available to support parents in supporting their children. Those who work directly with parents should be knowledgeable about the children s group process, content and goals. Roles should be clearly defined and delineated. 2. Engaging the Parent Facilitators should always meet with parents individually, and may provide the information described here in individual meetings.2 A group orientation with parents is helpful in family residential programs. In any case, it will be important to show parents where the children s group will be held. Children s ability to participate in and benefit from this program is largely dependent on parent and/or caregiver support. If parents have custody of their children (or are in frequent contact with children cared for by others) parents substance use, trauma and mental illness should be acknowledged with and by parents, even if parents are not yet fully engaged in treatment. Ideally, parents should be engaged in their own recovery work. Without this acknowledgment, children s recovery can be seriously restricted or worse, children can experience profound conflicts of disloyalty vs. disclosure of their own experiences. Keep in mind that despite experiences that may be terrifying or abusive, children will still fear losing a parent or losing a par- 2. Parent should be broadly defined and include those who provide physical care for children, such as grandparents and foster parents. Parents who do not have custody but are involved with their children, should be included in orientation and periodic check-ins. 3

7 ent s love. Therefore it is critical that they see that their parents support their participation in group. In describing details of the program, children s program facilitators should meet with parents either individually or in an orientation group (described in 3. Facilitators, below). Whenever possible, facilitators should greet parents who bring or pick up their children and should periodically check in with them. Parents should be supported in understanding that they are acting wisely and lovingly by supporting their children s participation. In addition, parents and other caregivers should be told what to expect from particular sessions, so they will be prepared if children bring up concerns raised in group such as parents substance use (session four), experiences with violence (session five) or inappropriate touch (session six). 3. Facilitators Facilitators should be knowledgeable and skilled in child development and child psychopathology; child group dynamics; and effects on children of parental substance use, mental illness and domestic violence. They should also be skilled in: Guiding children s behavior, using methods that contain rather than discipline children Conflict resolution with children Setting boundaries Children s experiences, and their disclosures in group, can unnerve even the most experienced clinician. Facilitators must have confidence, competence, excellent self-care practices and self-knowledge, and deep capacities to support and respond to children whose experiences have been profoundly traumatizing and whose behavior will test facilitator ability to ensure safety and containment. In addition, the ability to follow children s leads while keeping the child on safe ground will go a long way in supporting the child s recovery. Good, regular supervision is essential. Groups should have two facilitators, and a facilitator to child ratio of 1 to 3 or 4. Where possible, male and female co-facilitators provide balanced role models. Facilitators should model behavior by participation in activities with the children as appropriate. Facilitators should also be confident and competent in engaging parents, providing clear boundaries about confidentiality while supporting parents decisions to allow their children to participate. 4. Follow-Up Follow-up before and after group sessions, with parents, and between facilitators and parents service providers is essential. Parents should be alerted if a particular group was difficult for their child or other children. 4

8 While avoiding disclosure of children s own group experiences, parents can be prepared for the possibility that children may be upset, and may talk about group. Experience has shown this is particularly important after session four on substance use and session six on touch. Facilitators, and parents service providers should be skilled in providing guidance and support to parents without violating children s confidentiality. This distinction should be crystal clear to parents. Facilitator availability for a few minutes to chat before or after group will enhance the relationship with parents. 5. Group Setting The program can be offered in residential family settings as well as community settings, but keep in mind that the room where the group meets will affect the tone and perceived safety of the group. Within residential settings, it is important that the children s group be offered in a space that can be contained and can ensure confidentiality so children feel safe to talk about their feelings. The space should be welcoming to children. Children should be able to both sit comfortably and move around while engaging in activities. The space should allow for the whole group to sit in a circle, preferably on the floor, for the opening and closing of the group, and other group activities. Avoid couches, stuffed chairs or hard adult-size seating. It is helpful to have a quiet space apart from the group for children who become distressed or who need one-to-one attention. 6. Participants and Ages Ideally, groups should be offered by age groups, such as 5 to 7, 8 to 10, and This is not always possible, and is another reason two co-facilitators are important so that activities may vary by age group within the session. There should be no more than 3 or 4 children for each co-facilitator. Preparation 1. Parents Begin by scheduling an individual meeting with each parent to explain the group and explore ways in which the group may benefit her/his child as well as to discuss any issues that may arise. Ensure that the parent is also engaged in treatment and recovery. During this meeting, elicit the parent s assessment of the child, including what the parent sees as the child s needs, and what the parent hopes the child will get out of group. So that you get a sense of how the parent sees the child, ask the parent to describe the child s day; how the child acts during the day; and whether the child has had frightening experiences. It is critical to be transparent with parents that addressing effects of substance use, violence and mental illness underlie the design of this program, and that coordination with other service providers is critical. 5

9 Encourage parents to speak openly about their own experiences and to describe what their children may have witnessed or experienced. This meeting will form the beginning of the facilitator s relationship with parents. It is an opportunity to learn what might distress children in the group, as well as what might distress parents. For example, children who have witnessed their parents getting high might find the session on substance use (session four) challenging. This is also an issue when children participate in session five, Sharing Personal Experiences with Violence. Be sure to ask about any food allergies children might have, as well as any factors that might limit the child s participation. It is critical that the plan for transportation of the child be established in initial meetings with parents or caregivers. Be sure to check on this each session. 2. The Child At least one of the facilitators should meet the child before group, ideally in the room where the group will be offered. This is essential so the child knows that this will be a safe place. This initial meeting will help prepare both the child and the facilitator. Plan this meeting so there is time to show the child some samples from groups, such as an emoticon poster, or chimes or other cues that will be used (see Part 2: Session Structure). Note that some children may have a favorite stuffed toy or pillow or other object they would like to bring with them. Be sure to ask. This may help the child feel safer in the group and make the transition easier. 6

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