Thursday, June 6, 2019

Foundational Setting Events

I always appreciate good, thorough, meaningful assessment, if it informs and enhances good intervention/treatment.  Don’t shortcut assessment.
Evidence based interventions primarily fall into one of two categories: Developmental and Behavioral.  Over the past 10 – 20 years, these two approaches have come closer together. 
Typically, when looking at the “why,” or reason for a behavior, a good BCBA (behavioral) will look at the function of the behavior.  Is the child trying to avoid/escape/release, get something, or is it to fill a sensory need?  Skill and performance deficits will be considered.  Antecedents, Behavior, and Consequences, will all be considered, and they are all crucial and critical elements of an effective plan.
Developmental interventions work in a similar vein.  The interventionist and/or parent coach create the opportunity for the child to develop foundational developmental skills and then build upon those skills. The Greenspan Floortime ApproachTM is a good example.  Building upon the work of Dr. Greenspan, Dr. Richard Solomon developed The PLAY Project. See:  Autism: THE POTENTIAL WITHIN, The PLAY Project Approach to Helping Young Children with Autism. Richard Solomon, MD.  https://www.playproject.org/  (PLAY is an excellent evidence based and low-cost intervention for autism for many children and families. PLAY can significantly extend capacity for services for children with ASD at a relatively low cost.  It is not for all, but for some it can be a great boon.)
Therapists, educators, parents, should never underestimate the critical importance of fundamental, developmental building blocks and experiences.  Too often we attribute the lack of progress to a lack of motivation, or even simple skill building, when other critical issues are at play and must be addressed. 
Setting events will be considered as mentioned previously.  However, this appendix will take a much broader view of setting events, some of which are often overlooked or neglected, but which are fundamental for anyone, whether or not they have a disability or social/emotional difficulty.  Do not disregard the foundations of: physical, emotional, social, and mental health.
Let’s start with Maslow.  Almost anyone in the social sciences or education is familiar with Maslow’s Hierarchy of Needs.  It is something we learn about in Psychology or Social Work 101 and then we often forget it exists.  If the child, any child (or adult), does not have his/her basic physiological and safety needs met, you are unlikely to change or improve outcomes or behavior.  The same could be said for that child’s parent.  If you want to influence the parent as a partner for the good of the child, do not forget the parent also has basic needs.
For my purposes here, I only want to focus on the bottom three layers of Maslow’s Foundation.  Physiological includes physical needs (shelter, food, clothing, etc.), health and medical needs.  Safety would include adverse childhood experiences, which will be discussed next.  Safety also includes stability.  It is difficult to feel safe in instability.  Love and belonging are also essential and will be discussed after adverse childhood experiences.




Adverse Childhood Experiences

This model from the U.S. Substance Abuse and Mental Health Services Administration https://www.samhsa.gov/  refers to a large research project, the Adverse Childhood Experiences Study, sometimes referred to as ACES.  You can learn more about this study from many resources, including: https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-experiences
While this is an over simplification, the study found that the more adverse childhood experiences a child had (risk factors) the more likely they were to have social, emotional, & cognitive impairment.  This in turn increases the likelihood the child/adult will become involved with health-risk behaviors.  This in-turn increases the risk of disease, disability, and social problems, and ultimately early death.  However, well before early death, is poor quality of life.
What this pyramid does not demonstrate is the importance of protective factors.  Many people who have adverse childhood experiences go on to thrive.  Quite often the difference is the presence of protective factors, strength, or developmental assets.  You can learn about developmental assets which help children thrive here: https://www.search-institute.org/our-research/development-assets/developmental-assets-framework/
Though this may differ slightly from Maslow’s model, I always put safety first and immediate.  Resolving urgent, significant, immediate, safety concerns is always the priority.  In this context, I expect Maslow would agree.  While removing risk factors is important when possible, it is impossible to remove the past.  Inserting protective factors or developmental assets, especially those which fit the interest and/or need of the child can help ameliorate risk and reduce the negative effects of adverse childhood experiences. 
Additional intervention/therapy may also be needed.  Some children can benefit from trauma informed therapy and/or play therapy (not to be confused with P.L.A.Y.) provided by a well-trained, effective therapist able to build a positive rapport with the child and parent/guardian.





Please also consider the following pyramid model.


This is only part of The Pyramid Model from the Technical Assistance Center on Social Emotional Intervention for Young Children.  For more information go to: http://challengingbehavior.fmhi.usf.edu/do/pyramid_model.htm
Consider this pyramid, what do you think the outcome would be for the child and family if only the top and bottom levels of this pyramid were present?  The point of this model is the necessity of addressing each layer from the bottom up, before providing intensive individual intervention for the child, whenever possible.  While there may be some urgent situations where an immediate intervention may be warranted, in most situations, for most children with social-emotional needs, building the foundation can lessen or even resolve the need for intensive individual intervention.





Here’s another.  The Foundation for Personal, Optimal, Health.
          It can be very difficult to think clearly, feel well, and behave your best, when your body is fueled by crap and void of essential nutrients.  It is similar for a lack of sleep, exercise and/or significant chronic stress.
Our internal chemistry, how we think and how we feel is fueled or disrupted by what we put into our bodies; by the chemicals, liquids, and nutrients.
Do not underestimate the importance of this fact.



Personal Optimal Health
          Food Security is not about getting enough food to eat.  It is about getting the essential nutrients.  This is about getting all the nutrients your mind and body need to function well.  If you are food insecure, you will crave food.  Even if you were to eat a gallon of macaroni and cheese every single day, even two gallons of macaroni and cheese every single day, if that was all you ate, you would be food insecure.  I had a college roommate who tried that.  He became so sick he had to have vitamin shots to regain his health.  He was lucky, it could have been much worse.  For some it is.
          According to the World Health Organization, and perhaps for the first time in history, there are now more people in the world who are malnourished and obese than malnourished and underweight.  (See: http://weight-lossnewsandresearch.blogspot.com/2018/05/food-insecurity-paradox.html)
          Some believe it is too expensive to eat healthy, that is a myth, for most.  It is cheaper to eat healthy, and be healthy, even on food stamps, IF you know how.  Many can even eat more than they usually eat and still lose weight, if needed.  This is not something that can be remedied in one meal or one day.  If you or a child are seriously food insecure, it will take many weeks/months of good, well-balanced meals to rectify significant damage previously done.  In some cases, it may require medical intervention.  Occasionally it may be too late, but still important for personal optimal health, whatever that may be.   See: Food Addiction, Binge Eating, Addiction Recovery: Choose: Health, Life, and Love (with recipes) CR Petersen M.Ed.
          While only discussing a few aspects, all the pyramid is essential for anyone’s personal optimal health.
"With irrefutable evidence that children in low- and middle-income countries can be expected to develop optimally as long as basic needs for nutrition, safety and stimulation are met, policy makers and political leaders can now turn their attention to making it happen."



All of this speaks to the old metaphor comparing the fence at the top of the cliff to the ambulance at the bottom.  While we will always need the ambulance, these pyramids or foundations, bring attention to the need for a good strong fence.
Examples:
Many cases of autism and developmental disabilities can be prevented with nutrition before and during pregnancy.
Exercise and depression
This does not mean that exercise will eliminate depression.  In very few cases will it do that.  However; in many cases, it will ameliorate depressive symptoms.  Consult with your physician, take medication as needed.
Nutrition and mental illness
Again, good nutrition is not likely to eliminate mental illness, but in some cases, it may ameliorate symptoms. Consult with your physician, take medication as needed.
One other interesting article:
The road to Alzheimer's disease is lined with processed foods

According to the researchers at Vitalsmarts https://www.vitalsmarts.com/, we are influenced by both motivation and ability, and for both, at the levels of personal, socials, and environment.  At the personal motivational level, we might include: sensory needs, wanting something, and escaping from something.  These may include motivators pertaining to health, and internal feelings such as pain.   Personal ability may include other aspects of physical health and disability, as well as other areas of personal ability.
          Hopefully you are now well beyond only thinking about the basic motivators of avoiding or escaping, getting something desired, or sensory needs.  Those are important, even critical, but they are not the whole story. 
          You may be asking yourself how you can know about all these levels in multiple pyramids.  While not a complete answer, the CANS or The Child and Adolescent Needs and Strengths http://weight-lossnewsandresearch.blogspot.com/2018/05/the-child-and-adolescent-needs-and.html  can fill in many of the pieces which may missing and where you can build on strengths.
Not only will it provide an assessment, but it will tell you of specific needs which may need to be addressed, and areas of strength which can be further ameliorated.  These strengths can be used to minimize the impact of some needs.  This does not mean that some serious and significant needs do not need to be addressed with urgency.  Urgent needs, especially around safety and stability, must often be addressed immediately.
Many years ago, I was a MANDT http://www.mandtsystem.com/
instructor.  At the time I was a clinician in a mental health agency.  It was common on average, on a weekly basis, that we would restrain and put at least one youngster in time out.  I know practically nothing about MANDT now, but at that time, while physical restraint was taught, avoiding the need and prevention, were emphasized.  Quite often, when foundations are created as demonstrated in the foregoing pyramids, crises are adverted.  While the MANDT training did not address anywhere near everything addressed here in this appendix, it addressed enough to make a substantial difference.  After going through the training, myself, and then training the staff at the agency, as I remember, we only had to physically restrain one child, one time, during the following year and a half.  That is a substantial improvement over doing it weekly.


No comments: