Transcript Child Adult Relationship Enhancement CARE

Child Adult Relationship Enhancement
CARE
Curriculum Developed by
Erica Pearl, PsyD; Barbara W. Boat, PhD; Erna Olafson, PhD/PsyD
at
Cincinnati Children’s Hospital
Trauma Treatment Training Center
CARE
Presented by
Dianne Jandrasits, PsyD
Teri Pentz, MS
Kristen Schaffner, MSEd, PhD Candidate
Matilda Theiss Child Development Center
Of Western Psychiatric Institute and Clinic of UPMC
Pittsburgh, PA
Child Adult Relationship Enhancement:
Two Parts
• Part I
– Involves following the child’s lead in order to
connect with the child
• Part II
– Involves discipline, including specific techniques to
improve compliance
Evidence Based Promising Practice
• Developed from empirically validated
treatment called Parent Child Interaction
Therapy (PCIT) developed by Sheila Eyberg
• Adopted by National Child Traumatic Stress
Network as a “Promising Practice”
What is PCIT?
• PCIT
– Developed for children ages 2-8 with Disruptive Behavior
Disorder(s)
– Play-based Dyadic Intervention
– Brief treatment (14-20 weeks to complete)
– Changes behavior from clinicilly significant problem to
non-problematic levels
– Evidence shows results last up to 6 years
Empirical Evidence for PCIT
• PCIT International website (www.pcit.org) provides an
extensive list of over one-hundred and fifty research studies
related to PCIT
• Outcomes of PCIT
– Decreased parental stress, more positive parent-child
interactions, more internal locus of control for parents, as well as
higher parental tolerance for their child’s behaviors (e.g., Boggs et al.,
2004; Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993; Schuhmann,
Foote, Eyberg, Boggs, & Algina, 1998)
– Significant decrease in child noncompliance, disruptive behaviors,
and activity level (Eisenstadt et al., 1993)
– A significant reduction in symptoms associated with Oppositional
Defiant Disorder, Conduct Disorder, and Attention-Deficit
Hyperactivity Disorder (Eisenstadt et al., 1993).
Empirical Evidence for PCIT
(continued)
• PCIT has demonstrated efficacy with a variety
of clinical and cultural populations. (e.g., Bagner &
Eyberg, 2007; Baurermeister, & Bernal, 2009; Chaffin et al., 2004;
Choate, Picnus, Eyberg, & Barlow, 2005; Matos, McCabe & Yeh,
2009; Timmer et al., 2006)
• Treatment gains have been maintained for
one to six years (Boggs et al., 2004; Hood & Eyberg,
2003).
Child Adult Relationship
Enhancement (CARE)
• Trauma-informed, field-initiated modification of
specific PCIT skills
• For general usage by non-clinical adults who interact
with traumatized children in a variety of settings
• Supported by pragmatic evidence of effectiveness
(CARE Manual)
Evidence Base for CARE
• According to the National Child Traumatic
Stress Network, although CARE has not
been studied extensively, due to the
substantial research base supporting PCIT
(treatment from which CARE was derived)
the intervention is considered a promising
practice with a sound theoretical basis.
Who Should Be Trained?
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Child Care Providers
Early Intervention Service Providers
Home Visitors
Educators and School Staff
Medical Professionals (Nurses, Pediatricians, Emergency Care Specialists, Dentists)
Adoptive Parents
Residential and Day Treatment Staff (including non-clinical staff)
Child Advocates
Foster Care Case Workers
Child Protection Workers
Police
Transportation Providers
What Does CARE Training Include?
• Lecture, Demonstrations, Practice
(3 hours)
• Lecture, Demonstrations, Practice, Live Coaching for
mastery of skills (6 hours)
• Training choice depends on setting, client
population, and agency goals.
Toys for Connecting with Children
Creative, constructive toys
• Building Blocks
• Legos, Duplos, Tinker Toys
• Mr/Mrs Potato Head
• Dollhouse with miniatures
• Crayons, paper, stencils, scissors
• Pretend toys: food, farm, garage, cars
• Play Dough and molds
• Dolls/stuffed animals
Toys
Part I:
Following the Child’s Lead
• Research shows these skills help adults build good relationships with
children, helping them feel safe and calm
• Following a child’s lead can help adults communicate with all children, esp.
those who are very active, oppositional, or shy
• Using these skills helps adults teach children effectively
• The interaction can improve a child’s willingness to comply
• Following the child’s lead tends to improve the child’s social skills, e.g.
sharing
Part II:
Adult Directed Interaction
• Discipline
– Involves specific techniques to improve child’s
compliance
– Not recommended for dangerous, destructive
behavior
Part I
Skills: Minding Your “P’s and Q’s”
Two sets of Rules
– “Do” Skills (P)
• Can be used in many interactions with children
throughout the day
– “Avoid” Skills (Q)
• Can be used in a variety of settings but there are some
limits
“Do” Skills: P’s
• Praise (Labeled) appropriate behavior
• Paraphrase appropriate talk
• Point Out child’s appropriate behavior
Praise (Labeled) Appropriate
Behavior
• Praise is a compliment about a child or his/her
behavior
• Two Types of Praise
– Labeled: Specific about what you like
• “You chose such pretty colors!”
• “ I like how you write so neatly.”
– Unlabeled: Nonspecific praise
• “Good!”
• “Nice job.”
• “You’re so smart.”
Praise
• Labeled is better than Unlabeled because it lets the
child know exactly what the adult likes
• Increases the likelihood that the behavior will occur
again
• Adds more warmth to a relationship with a child
• Makes both adult and child feel good!
Praise (Labeled)
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You’re very good at remembering your supplies.
Great job getting your homework done!
You’re doing such a great job of working hard.
Great idea to draw it that way.
That was kind of you to ask her to join in.
This is a terrific cake we made together.
That is a wonderful story you told.
I appreciate how clearly you explained that.
Good job finding that puzzle piece!
You’re doing a great job playing calmly.
Paraphrase Appropriate Talk
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Paraphrasing is reflecting or repeating back all or
part of what the child says
Examples
– Child: “Big train.” Adult: “Yes, that IS a big train.”
– Child: “Give me the car.” Adult: “You want the car.”
– Child: “The clown makes me laugh.”
Adult: “The clown is funny.”
– Child: “This piece don’t fit.” Adult: “That piece doesn’t
fit.”
Paraphrase Appropriate Talk
• Allows the child to lead conversation
• Shows the child you’re really listening
• Shows you accept and understand what s/he is
saying
• Improves and increases the child’s speech and
conversational skills
• May feel awkward at first but children LOVE it!
Paraphrase
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You did make dinner!
You’d like to see that movie…
You feel overwhelmed with work.
The show is funny!
You had to run more than usual today.
Point Out Child’s Appropriate
Behavior
• States exactly what the child is doing
• A running commentary, like a sports
announcer on the radio
• Describe each little thing and include the
words, “you are…”
Point Out Child’s Appropriate
Behavior
• Let’s the child lead
• Let’s the child know you’re interested & paying attention to him or her
• Let’s the child know you approve of what he or she is doing
• Models speech and teaches vocabulary and concepts
• Keeps the child’s attention on the task & teaches child how to keep his or
her own attention on a task
• Helps organize the child’s thoughts
Point Out Behavior
• You’re making brownies for the party.
You’re sitting very quietly.
You’re drawing a picture.
You lined up all the blocks.
You’re getting organized.
You put them together.
You put the girl inside the truck.
“Avoid” Skills: Q’s
• Avoid Unnecessary Questions
• Quash the Need to Lead by Avoiding Commands
• Avoid words like
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Quit
No
Don’t
Stop
Not
Avoid Unnecessary Questions
• Two Types of Questions
– Information
• Who, what, where, when, how
– Tone-of-Voice
• When the voice goes up at the end of the sentence but
the person is not really asking for information (lilt)
Questions
• Take the lead away from the child because they require an
answer
• Are often hidden or indirect commands, such as, “Would you
like to build a house?”
• Sometimes suggest disapproval
• May leave child feeling that the adult is not really listening
Quash the Need to Lead by
Avoiding Commands
• Commands
– Statements that try to direct play or conversation by suggesting what a
child should do or what s/he should talk about
• Two Types of Commands:
– Direct: “Sit down.” “Tell me what you did today.”
– Indirect: “Would you like to___?” “Let’s put the cars
away.”
Quash Need to Lead by Avoiding
Commands
• Commands take the lead away from the child
• If the child doesn’t obey the command, the connection can be
lost because the play is no longer fun
• Commands will be discussed in greater detail when we discuss
discipline phase of CARE
Avoid Negative Talk: Quit, No,
Don’t, Stop, Not
• Negative Talk
– Negative or contradictory statements about the child or his/her
actions that usually include the words, “Quit - ,” “No –,” “Don’t - ,”
“Stop - ,” and “Not - .”
• Examples
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“Quit bothering your friend at circle.”
“No, that’s not how we do it.”
“Don’t forget to throw away your milk carton.”
“Stop banging the blocks on the table.”
“That’s not nice.”
Negative Talk:
Quit No Don’t Stop Not
• Often creates an unpleasant interaction
• May make the child feel bad about herself or himself
• Rarely works to decrease undesired behavior and often
increases the criticized behavior
• Points out mistakes
Negative Talk
• Exercise
– Recall familiar negative talk typically heard as a child
• VERY difficult habit to break
• What should I say to a child?
– Lots of other things to do & say
– We’re not eliminating “Avoid” skills entirely, but the following skills are
emphasized to enhance connection with children
– These skills can be utilized during playtime and times when it is not
imperative for the adult to be in charge
What About Inappropriate
Behavior?
• When adults apply P’s and Q’s children often
display good behavior…but not always
• What do we do if a child misbehaves?
Strategic Ignoring
• Strategic (planned) ignoring is a powerful tool
for decreasing or eliminating undesired
attention – seeking behaviors
• What behavior cannot be ignored?
• What behavior can be ignored?
Strategic Ignoring
• Any attention, positive or negative, can increase the negative behavior
• Avoid any verbal or nonverbal reaction to the behavior (e.g. looking at the
child, smiling, frowning, etc.).
• Once you begin ignoring, it is essential that you continue to ignore until
the behavior stops (e.g. tantrum at check-out)
• Continue ignoring until the child is doing something appropriate
• Praise the child immediately for the appropriate behavior. This helps the
child notice the difference between responses to good vs. bad behavior.
• CAUTION: behavior gets worse before it gets better
• Consistent ignoring eventually decreases many undesired behaviors
Strategic Ignoring
• Change negative behavior to positive by
Praising Positive Opposites
– While ignoring (-) behavior, look for any (+) behavior occurring at the
same time and comment on it
– Any time you see behavior that is the opposite of problem behavior
you have to ignore, give the child a BIG labeled praise for the “positive
opposite”
– If a negative behavior stops, comment immediately on what the child
is doing that is the opposite of the negative behavior
Mastery of P’s & Q’s
• Purpose of Mastery Testing
– For trainees to practice skills and receive helpful feedback
– Information practiced soon after learning is remembered best
• Coding
– See CARE skills coding sheet
– Code for 3 minutes
– Goal:
• 5 Praises (Labeled), 5 Paraphrases, and 5 instances of Pointing out
Behavior
• 3 or fewer total Questions, Commands & Negative Talk
Part II
Skills: Giving Good Commands
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Make Commands Direct
State Positively
One at a Time
Make Commands Specific
Use Age-Appropriate Commands
Give Commands Politely and Respectfully
Use Neutral Tone of Voice
Offer Developmentally Appropriate Choices
Limit Explanations
Use “5 Second Rule” to Give Time to Comply
Giving Good Commands
• Use “5 Second Rule” to Give Time to Comply
Giving Good Commands:
5 Seconds for Compliance
• When a child is dawdling, we must decide whether he or
she is making a move toward compliance
• While trying to decide, say nothing to the child and
SILENTLY count to 5 in your head. If he or she doesn’t
comply by the end of 5 seconds, this is considered
noncompliance
• Always provide labeled praise for compliance with
commands
Determining Compliance vs.
Noncompliance
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Do I praise a child if they write their name at the bottom of the page but I told
them to write it at the top?
Even though the child did write his or her name, the specific command was to
write it at the top of the page. When a child does something slightly different
from your command, it is noncompliance and does not get a Labeled Praise.
If I have told the child, “Please put the box on the shelf” and she slams it down
while yelling, “I put the stupid box away!” what do I do?
The command was to put the box on the shelf and the child did so. The best thing
to do is to ignore the attitude and praise the compliance. Bad attitudes will
disappear when you give them no attention.
Broken Record
• Technique for adults to practice giving a direct,
positively stated command while keeping a
neutral, consistent tone of voice
Broken Record
• Choose a command where compliance isn’t critical (Please sit down)
• Noncompliance? Give command 2nd time using EXACTLY the same words.
Remain quiet (counting silently and slowly to 5), point to assist the child in
understanding, and maintain neutral facial expression. If the child
complies, provide enthusiastic Labeled Praise!
• Noncompliance? Give command 3rd (and final time) using EXACTLY same
words and neutral but firm tone of voice. Again, remain quiet (counting
silently to 5), point to assist child in understanding, and & maintain neutral
expression. If child complies with this 3rd command, provide Labeled
Praise.
• Noncompliance? Ignore him or her by turning away for walking away for
30 seconds to one minute.
Summary and Conclusion
• CARE teaches techniques and skills which promote
positive adult-child relationships while increasing
compliance by use of effective commands
• This presentation provides an overview of the program,
but not full training
• For more information on receiving training for your
organization, please contact Dr. Jandrasits
([email protected]) or Ms. Schaffner
([email protected])
Questions?