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Developmental Repair

(Originally published November 2011)

In the past two Sounding Boards (September, October) , I wrote about the difficulty traumatized and severely neglected children have with emotional regulation; and the beliefs and expectations regarding caregivers and themselves in relation to caregivers (i.e., internal working models) that, if unchecked, have the potential to lead these children toward social exclusion, academic failure, delinquency and prison. Child welfare systems have not yet found effective means of stabilizing oppositional and conduct disordered children in care, much less repairing the development harms resulting from early histories of child maltreatment and other adversities. Trauma informed programs and practices are urgently needed that can help caregivers and professionals respond to the extraordinary challenges presented by highly aggressive emotionally unregulated children in a manner that builds nurturing relationships, reduces problem behaviors and changes children’s fundamental beliefs about the world. This is a challenge child welfare agencies have only recently begun to understand and face up to through trauma informed practice initiatives and erratic implementation of a few evidenced based programs.

In this Sounding Board, I describe a program for children, 3-8, with aggressive disruptive behaviors developed by the Washburn Center for Children in Minneapolis, Minnesota in consultation with Dr. Anne Gearity at the University of Minnesota. The Washburn Center for Children is a non-profit community mental health agency that has developed a day treatment practice model named Developmental Repair. It is an intervention that takes seriously the beliefs and inner worlds of traumatized children as well as helping them develop pro-social behaviors.

Developmental Repair has a few main goals:

Repairing children’s internal capacity for self-regulation through nurturing relationships with adults
Enhancing children’s ability to reflect on their experiences and to think before they act
Challenging children’s negative beliefs about caregivers and other people through repeated experiences of kindness and active interest in the fears and expectations leading to aggressive behaviors.
Encouraging social reciprocity and effortful control of negative emotions required to maintain positive relationships with caregivers, teachers, siblings and peers.

Gearity describes the children Developmental Repair is designed to help as follows:

They expect adults to be harsh or unavailable, and they provoke the reactions they expect.
They assume their needs will be ignored so they rarely seek or accept adult help.
They make outrageous and unrealistic demands.
Requests that ask for compliance usually turn into power struggles.
Their feelings are easily triggered but confused by physical sensations that are called arousal.
Ordinary social expectations threaten them so they wreck social experiences.
When sad, disappointed or surprised, they react with anger and aggression.
They show low frustration tolerance so new learning is hard.
They perceive danger much of the time, and assume they could be hurt.
They misread social cues and often assume retaliatory aggression has occurred when none was intended.
They don’t remember what happened in the past, and they can’t think about or explain their own experiences.
Because they have poor language skills, or don’t rely on words, they resort to actions like hitting, kicking, spitting and swearing.
They anticipate difficulties, but rarely seem to learn from new experiences.

Gearity comments that “Given the relatively young age of these very at risk children, it is striking how hard it can be for adults to be with them.” Often, they alienate foster parents, child care staff and teachers who begin to describe them in negative terms and quickly conclude that they cannot be helped. Gearity states that “It is not surprising that most people want to leave them alone. Their dysregulation is contagious …” She continues, “Adults often feel confused, abused and unsettled. Yet they also can feel exhilarated when real connections are made…”

Developmental Repair trains caregivers, child care staff and teachers to understand children’s aggressive out of control behavior as a desperate reaction to intense fear and panic and their best effort at emotional regulation given their distrust of caregivers. The model prepares adults to be regulatory partners by helping children ‘Come back’ from intense states of arousal followed by “dissociative obliviousness or disinterest.” Gearity asserts that “This happens not with attention to whatever triggered their arousal, but with interest to their own internal experience (You got so worried and it turned into big feelings and you didn’t know I could help). Coming back stays with their feelings and perspectives, and helps them become soothed in the moment.” Gearity maintains that children must be able to tolerate their internal states before they can comprehend how their actions affect others.

According to Gearity, “Coming back to arousal regulation must happen again and again and again until the child expects that this is possible with adult help.” And she adds, “Developmental Repair uses moments of arousal dysregulation to work on children’s developmental ability to trust that adults will help them stay regulated enough to learn.” Children’s willingness to use adults to calm down is the first step in learning how to become more self-regulating in this model. Gearity contrasts Developmental Repair with other interventions that “ask children to accommodate to adult expectations.” This is a model that asks adults in key caregiving and teaching roles to imaginatively connect with the mental and emotional worlds of troubled children, a demanding requirement when adults are attempting to manage child behavior and influence children to complete tasks.

Nevertheless, Gearity goes to great lengths to distinguish Developmental Repair from behavioral interventions. She states that the model “actively works to repair reflective thinking.” “We help children become aware of thoughts that reveal feelings and direct actions. We also help them to see and understand the thoughts, feelings and intentions of others,” she adds. Further, the model has the goal of motivating children to learn new ways of functioning instead of relying on external controls.

Developmental Repair trains adults to join with children through interest, empathy and kindness. “Adult kindness provides the necessary glue that helps these children stay regulated …”, Gearity writes. Adults must be able to tolerate unprovoked attacks and remain interested in children’s experiences. Gearity maintains that “By staying interested, we can regain our regulatory balance, and bring them back with us.”

It is the model’s recommended response to non-compliant child behavior that most clearly distinguishes Developmental Repair from behavioral modification. Gearity writes that “When they refuse to follow directions, we become interested in what they have perceived. When they act aggressively, we anticipate their fear of retaliation and avert power struggles as much as possible. They expect a disconnecting impasse. We offer concerns about their feelings. Even when we stop behaviors, express disapproval and set limits, we offer a joining stance. Our interest is more on the child than the behavior.” A behavior management specialist might view these responses as a way of rewarding non-compliant behavior. At the very least, Developmental Repair appears to make complex difficult to reconcile demands on program staff.

Developmental Repair teaches young children to seek adult help when they become distressed in a process referred to as Hire. “They must start to actively seek out our help…,’ Gearity states. Initially, Gearity asserts, aggressive children hire and then fire staff when they are angry. “Hiring also includes their desire to keep us involved as they manage new situations and look for our approval and admiration (positive emotions that have been strikingly absent),” Gearity writes.

Gearity has insightful things to say about offering children the regulatory help they can tolerate. She comments, “Sitting quietly (and not expecting eye contact or verbal communication) allows many children to take in soothing company.” She states that aggressive children avoid physical contact or startle at touch because they expect to be harmed. “Adults need to restore touch as a normal part of relating so that children can stay in their bodies,” Gearity states.

Developmental Repair is a group treatment that helps children feel secure with multiple adults and to ‘hire’ several adults in the program, though Gearity admits that children often come to prefer a special staff member who understands them and is able to calm them down.

Gearity describes therapeutic progress as a rocky road. Children work hard to elicit the negative reactions they expect from adults. According to Gearity, “they accept help but then become contemptuous of the helper; they anticipate disappointment regardless of what adults do; when they feel vulnerable, they become humiliated and inconsolable. Many children provoke rejection to prove their doubts.” Gearity comments,” Staff working with these very at risk children have described feeling as if on an improvisational stage without a script …”

Nevertheless, Gearity insists, program staff, caregivers and teachers must not give up. Children struggle to maintain maladaptive beliefs even as a better life is offered to them. “When adults continue to make efforts for joining, most children succumb. Developmental Repair assumes that young children want to feel cared for and connected to adults, even if they doubt this possibility,” Gearity asserts.

Gearity comments that program staff and caregivers are put to the test in “stormy moments” when children become intensely aroused and disruptive. “Joining is most critical, and most challenging at these times,” she writes. Anyone who has ever helped to restrain a child or adolescent experiencing an emotional meltdown in residential care is likely to have long lasting memories of the experience. “Instead of shunning these children when they become aggressive, we seize this opportunity to provide care and regulating help when they most need it,” Gearity states.

Gearity offers the following tips for adults whose task is to decelerate children’s arousal and aggression and to maintain connection so that regulatory help is possible:

Be quiet
Breathe slowly and intentionally. Gearity states that “children automatically copy this rhythm. Breathing interrupts hyperventilation and makes children aware of the adult as present but not threatening.”
Use eye contact – or not. “Some children need to be seen. Others will scream “don’t look at me,” so don’t. Joint eye contact can signal a return to connection,” Gearity states.
Verbally match. “Verbal sounds signal our presence and attentiveness…” The point of words is to quiet arousal fury and panic, rather than to explain the situation,” Gearity asserts.
Stay in the present experience. “When children are highly aroused, explanations about what happened or directions about what they should have done assault the child’s already fragile equilibrium,” Gearity writes.
Remain physically near as the storm passes through. Gearity comments that “When children become certain the adult will remain available, their panic lessens, as does their fury. Arousal becomes like riding a wave instead of drowning.” Time in, rather than time out is the best strategy.
Find distractions that can be shared. “Shifting attention, repetitive play (like tossing a ball), physical movement, introducing a positive idea can dissipate arousal and restore connection,” Gearity states.
Recognize when the child has come back to a less aroused state. Gearity comments that “positive emotional support at this moment helps children tolerate their fear and shame” resulting from loss of emotional control.

Developmental Repair is designed to help children reflect on their thoughts and feelings and the thoughts and feelings of others. Gearity comments, “We offer shared awareness – we take their perspective as what is important. But we add to their perspective – we read their faces and bodies and behaviors and imagine what is happening inside them.” Staff “put into words what we see,” for example, There was too much noise and you got so wound up and didn’t know what to do. When you feel that yucky excited feeling, you get scared inside.

Staff read emotional undercurrents which can trigger behaviors by beginning with their own thinking and then guessing the child’s side of the exchange. For example, You thought I wouldn’t listen to you, so you got really mad and knocked that over. But I wanted to listen. You didn’t believe me when I said that. You believed your worry instead. We had a misunderstanding.

Staff uses shared awareness to model reflective thinking. Gearity comments, “When children can reflect about their own experiences and feel organized by their own thoughts, then they can start to address worries and agitation from home and school.”

Developmental Repair encourages children to engage in self care (e.g., brushing their teeth) and to use positive self talk, for example, When you are at school, try to remember what I say, and then you can say the same thing to your mind – calm down, I can figure it out, it will be ok. You can do that instead of yelling. Talk to yourself.

As children acquire the capacity for self reflection, they are helped to identify discrete feelings other than anger and arousal and develop a vocabulary with which to think about their feelings. “Intervention helps children know what they are feeling with adult help so they can name what is occurring inside them,” Gearity states. Children need adult help in feeling distressing emotions and losing and regaining emotional control, Gearity believes, a process that must be repeated again and again for children to feel confident they can acknowledge negative feelings without losing control.

Gearity comments that increasing emotional regulation permits room for positive feelings. Because even positive feelings activate arousal for some children, they are a source of anxiety. In addition, “as children can tolerate and understand their emotions, they become more secure and kind toward others,” Gearity states. She adds, “It is cruel to blame them (children) for lacking empathy until it has been provided to them.”

There is more in Developmental Repair about helping children to manage behaviors and to become active in looking out for themselves; but behavior control is believed to develop out of children’s capacity for emotional regulation and after learning ways of responding to distressing events other than lashing out and attacking others. Gearity concludes, “As much as possible, behaving differently must be their choice, to counteract children’s fears of losing control and feeling helpless. Our interest remains on them, rather than making them behave.”

Developmental Repair is a well thought out framework for working with traumatized and neglected children that can be used by caregivers, teachers and other professionals. Like other mental health treatments, Developmental Repair cannot substitute for nurturing caregiving however; and there is a serious question about its potential effectiveness if birth parents or foster parents continue to provide harsh (if not abusive or neglectful) non-nurturing care while their children participate in day treatment. Gearity maintains “that even when families are not fully involved (in the program), this approach has efficacy. While children with involved families made the most gains, children with compromised family involvement also made reasonable developmental gains, especially when they experienced strong community support (school).” This is an encouraging conclusion, but many scholars, advocates and practitioners will insist on seeing independent evaluations that carefully connect family involvement to children’s developmental outcomes before becoming enthusiastic about implementing this model.

Reference

Gearity, Anne, Developmental Repair: A Training Manual, Washburn Center for Children, 2009.

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