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? 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) 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 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 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 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 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 or contradictory statements about the child or his/her actions that usually include the words, “Quit - ,” “No –,” “Don’t - ,” “Stop - ,” and “Not - .” Examples “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 VERY difficult habit to break 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 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

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 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 (jandrasitsdm@upmc.edu) or Ms. Schaffner (schaffnerkm2@upmc.edu)

Questions? ?