Child Adult Relationship Enhancement CARE

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Child Adult Relationship EnhancementCARE

• Curriculum Developed by
• Erica Pearl, PsyD Barbara W. Boat, PhD Erna
  Olafson, PhD/PsyD
• at
• Cincinnati Childrens Hospital
• Trauma Treatment Training Center

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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

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Child Adult Relationship Enhancement Two Parts

• Part I
• Involves following the childs lead in order to
  connect with the child
• Part II
• Involves discipline, including specific
  techniques to improve compliance

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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

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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

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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 childs 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).

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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).

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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)

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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.

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Who Should Be Trained?

• 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

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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.

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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

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Toys
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Part I Following the Childs Lead

• Research shows these skills help adults build
  good relationships with children, helping them
  feel safe and calm
• Following a childs 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 childs willingness
  to comply
• Following the childs lead tends to improve the
  childs social skills, e.g. sharing

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Part II Adult Directed Interaction

• Discipline
• Involves specific techniques to improve childs
  compliance
• Not recommended for dangerous, destructive
  behavior

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Part ISkills Minding Your Ps and Qs

• 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

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Do Skills Ps

• Praise (Labeled) appropriate behavior
• Paraphrase appropriate talk
• Point Out childs appropriate behavior

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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.
• Youre so smart.

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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!

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Praise (Labeled)

• Youre very good at remembering your supplies.
• Great job getting your homework done!
• Youre 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!
• Youre doing a great job playing calmly.

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Paraphrase Appropriate Talk

• 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 dont fit. Adult That
  piece doesnt fit.

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Paraphrase Appropriate Talk

• Allows the child to lead conversation
• Shows the child youre really listening
• Shows you accept and understand what s/he is
  saying
• Improves and increases the childs speech and
  conversational skills
• May feel awkward at first but children LOVE it!

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Paraphrase

• You did make dinner!
• Youd like to see that movie
• You feel overwhelmed with work.
• The show is funny!
• You had to run more than usual today.

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Point Out Childs 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

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Point Out Childs Appropriate Behavior

• Lets the child lead
• Lets the child know youre interested paying
  attention to him or her
• Lets the child know you approve of what he or
  she is doing
• Models speech and teaches vocabulary and concepts
• Keeps the childs attention on the task teaches
  child how to keep his or her own attention on a
  task
• Helps organize the childs thoughts

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Point Out Behavior

• Youre making brownies for the party.
• Youre sitting very quietly.
• Youre drawing a picture.
• You lined up all the blocks.
• Youre getting organized.
• You put them together.
• You put the girl inside the truck.

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Avoid Skills Qs

• Avoid Unnecessary Questions
• Quash the Need to Lead by Avoiding Commands
• Avoid words like
• Quit
• No
• Dont
• Stop
• Not

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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)

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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

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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___? Lets put the
  cars away.

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Quash Need to Lead by Avoiding Commands

• Commands take the lead away from the child
• If the child doesnt 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

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Avoid Negative Talk Quit, No, Dont, Stop, Not

• Negative Talk
• Negative or contradictory statements about the
  child or his/her actions that usually include the
  words, Quit - , No , Dont - , Stop - ,
  and Not - .
• Examples
• Quit bothering your friend at circle.
• No, thats not how we do it.
• Dont forget to throw away your milk carton.
• Stop banging the blocks on the table.
• Thats not nice.

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Negative TalkQuit No Dont 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

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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
• Were 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

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What About Inappropriate Behavior?

• When adults apply Ps and Qs children often
  display good behaviorbut not always
• What do we do if a child misbehaves?

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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?

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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

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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

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Mastery of Ps Qs

• 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

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Part IISkills Giving Good Commands

• 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

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Giving Good Commands

• Use 5 Second Rule to Give Time to Comply

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Giving Good Commands5 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 doesnt comply by the end of 5 seconds, this
  is considered noncompliance
• Always provide labeled praise for compliance with
  commands

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Determining Compliance vs. Noncompliance

• 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.

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Broken Record

• Technique for adults to practice giving a direct,
  positively stated command while keeping a
  neutral, consistent tone of voice

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Broken Record

• Choose a command where compliance isnt 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.

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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
  (jandrasitsdm_at_upmc.edu) or Ms. Schaffner
  (schaffnerkm2_at_upmc.edu)

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Questions?
?