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.
For more information on
Maslow’s Hierarchy of Needs, you can find resources here: http://weight-lossnewsandresearch.blogspot.com/2018/04/maslows-hierarchy-of-needs.html
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.
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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.
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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.
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http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30003-2/fulltext
"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."
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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:
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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
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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.
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.
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