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   BEST Buddiez:  A Programmatic Innovation in

   Early Child Mental Health Treatment for Physically Aggressive Preschool Children 
 

    “I have autism…I was lucky to begin early educational intervention when I was two and a half years old.  Back in 1949 most children with autism were sent away to institutions.  At age two ad a half I had all the full-blown symptoms of autism:  no language, no eye contact, and lots of tantrums.  Mother fought with many professionals who wanted to put me in an institution, but she was also lucky to find professionals who were willing to help…the people who helped me the most were the more unconventional, creative individuals.”  –Temple Grandin, Ph.D. 
     

   A pilot program at Learning Together in Raleigh, N.C., incorporated research based practices and community professionals’ expertise to work with birth to five year olds, and developed an innovative systemic course of mental health treatment entitled BEST Buddiez, an acronym standing for the prevention themes of Boundaries, Empathy, Self-esteem, and Thinking.  The overall socially proactive concept of a group of  “buddies,” in fact, best friends, allows for group work on a three and four year old level for their own individual issues of social difficulty.  Certainly, not all of the children in the program are to a point that they can participate in the group modality, but the concepts are still worked into the individual therapy, aiming to prepare them for group interactions at a later date.

   During the past 33 months, over 85 families have sought mental health treatment for their children at Learning Together.  Of those children, over 35% have had some sort of foster care history, 65% of them are under low income or poverty level, 53% of them are African American, 32% of them are Caucasian, 10% of them are Hispanic, and 6% of them are other, including biracial African American and Caucasian, Native American, Asian, and African.  Frequency of diagnoses have occurred at approximately 29% for Oppositional Defiant Disorder, 15% ADHD, 14% Autism, 12% Adjustment Disorder, 9% PTSD, 6% Bipolar Disorder, 5% Psychosis NOS, 4% Sensory Integration Disorder, and 4% Anxiety Disorders.   

   The primary goal of the program was to stabilize these children in their childcare settings, and to bring the physical aggression down to within normal developmental limits.  The primary treatment objective to stabilize these children prior to discharge from the Child Mental Health program has been met 100% prior to discharge.  That is not to say that these children will never have a need for ongoing mental health treatment on into life, but 85% of these children were discharged with no on-going therapy after discharge.  The other 15% upon discharge had significant mental health issues necessitating on-going care from a child psychiatrist or developmental pediatrician for med management.        

   The single most recurrent symptom of these children has been physical aggression:  toward siblings, peers, parents, teachers, household pets, strangers, or themselves in terms of head banging, hair pulling, hitting, slapping, and running into walls.  22% of these children had been expelled from a childcare setting at least once, another 19% were referred because they were going to be discharged due to their uncontrolled rages, 16% were never accepted into schools because of their behaviors, and the other 43% had other serious issues which threatened their long term health and daycare placement including physical abuse, witnessing domestic violence and suicide, and extreme introversion and depressive symptoms.

   “Solution-focused In-role Play Therapy”, as we have coined it, characterizes the BEST Buddiez program, which is largely based in Stanley Greenspan’s Floor Time play therapy techniques. Dr. Stanley Greenspan, founder of the Developmental, Individual Difference, Relationship-Based (DIR) intervention approach, pioneered Floor Time with children diagnosed with Autistic Disorder (Greenspan and Wielder, 2000).  It became apparent while working with children with various mental disorders characterized by physical aggression that the inability to relate socially with warmth and pleasure was not just symptomatic of autism, but almost across the board with all of the disorders that caused children to be expelled from their childcare setting. Solution-focused In-role Play (SIP) Therapy accentuates the relationship in particular between the child and the therapist.  SIP Therapy is a relationship-based play therapy in contrast to child-centered play therapy (Landreth, 2000), and the main “tool” is the therapist him/herself (Powers, 2000).  Solution Focused In-role Play Therapy  utilized in BEST Buddiez is characterized by:

  • Active play sessions, which occur on the floor. 
  • The relationship built between the therapist and the child becoming paramount in its warmth, enjoyment and range of affect as the sessions progress.  Soon this relationship will shift to the parent-child relationship, as the therapist models the skills to the parent and coaches their interactions. 
  • The therapist encourages the child to choose the play, and shows a genuine interest in this little person’s interest, rising above gender issues as well as developing the ability to relate to a wide range of toy play.
  • The therapist non-judgmentally follows the lead of the child.  If a particularly violent child starts out by “killing” the characters that he/she chooses in play, the therapist certainly does not kill off the other characters, but can go with the theme of the play and simply ignore the finality of death.  Children in this age group do not grasp the finality of death and are quite willing to treat the victim as merely hurt very badly.  The therapist can utilize the violence of the situation to let the child play out their inner world.  Taking notice of what precipitates an outburst in play is tantamount to the progress of the sessions.  Children who have gone through some sort of physical or sexual abuse will gravitate to re-enacting these horrors. (James, ’96)   Fortunately, these episodes call upon a rescue theme very nicely, which can be very emotionally meeting for these little ones, who cannot deal with the totality of their abuse, but can move through it eventually in play, until it can be resolved within themselves.
  • The therapist imitates the motor movements of the child in play.  If the child is predisposed to liking the sound and feel of plastic blocks clunking against each other, the therapist imitates this same pleasure in play.  If the child likes a particular sound, or a particular motion, the therapist facilitates a common ground, into which children feel drawn, especially those children who feel socially isolated by their maladaptive behaviors.
  • The therapist mirrors the emotions of the child initially, if only in facial gesture and tone of voice, and then gears the modulation of the mood according to the individual child thereafter. 
  • The therapist attends to how the child relates or avoids relating to his/her world. For example, if a child avoids eye contact, the therapist starts out avoiding eye contact with the child and draws attention away from direct eye contact onto a prop or toy that suits that child’s interests. 
  • The therapist then builds upon the interest of the child in an affect-building play session, which extends beyond the comfort level of the child, systematically desensitizing the child to more appropriate physical proximity.  Some children whose boundaries are loosely built, force too much familiarity too fast, and the therapist has to accustom this child to a more appropriate distance, without making the child feel rejected.  Other children who cannot tolerate physical proximity or physical touch, have to set their own pace, and the therapist must take the child’s cues as to how close he/she will allow the therapist to situate themselves.
  • The therapist aims at staying “in-role” for the entire session, until it is time to terminate.  Projecting these personas onto the toys that the child chooses, the therapist for a moment in time becomes the vehicle, the plastic dinosaur, the plastic man, the farm animal, or in the case of younger children, who are just beginning to experience the joy of pretend, the therapist must become the character itself.  Whole body involvement, full of activity and demonstrative energy is all the more engaging to small children.  The therapist, for the majority of the play session, takes on different voices, and different demeanors, and finds which types of personalities in play that the child enjoys most. 
  • The therapist expands upon the child’s choices in play to develop a whole play schema, which allows the child to gently take on unfamiliar roles of nurturing and rescuing, patience, and generosity.  As the child takes on these new virtues, the therapist has the unique opportunity to encourage and reinforce. 

 
 

   The BEST Buddiez group sessions utilize all of the above principles, bringing together up to 6 boys or girls, three or four years of age.  Children who are ready for the group modality have an opportunity to interact with the other children, so as to give the therapist an opportunity to deal in vivo with the child’s heightened difficulty with frustration tolerance, delay of gratification, turn taking, sharing, or sensory overload.  All these issues are thereby addressed in a microcosm of a classroom with similar structures of a classroom.  The sessions are held from an hour and a half to two hours, and the entire series consists of 8 sessions.  The group sessions have the following components:

  • A “Play World” is set up for each new session to include a whole dramatic theme around train play, dinosaur world, emergency world, barnyard day, Hawaiian Luau day, etc.
  • Each morning the children start out with a BEST Buddiez song and topic for the day (Boundaries, Empathy, Self-esteem, or Thinking) from a BEST Buddiez videotaped lesson, filled with puppets, music and interactive dialogue between the therapist and children.
  • Free play takes on the largest part of the day, in which SIP therapy as outlined above is woven into the group free play.
  • During the free play the clinicians are building a strengths-based emphasis into the session, by highlighting to one another the use of the skills being worked on in BEST Buddiez.  BEST Buddiez badges are awarded as the children demonstrate their use of the themes. 
  • The children are able to avail themselves to art therapy, dress up corner, housekeeping, and the play world of the day encompasses all of these in some way. 
  • A nutritious snack reflects the play theme of the day, whether it be a fresh cut pineapple for Hawaiian Luau day, creating a pig out of a hard boiled egg for barnyard day, or a cheese and cracker train for “All Aboard” day, during which they practice their good manners, or “magic words.”
  • The final segment is the BEST Buddiez song once again, which the children learn to sing and participate in the hand motions.  The children are encouraged to extend a “Bye-bye BEST Buddy!” to each of the friends participating.
  • A daily report with a “BEST Buddiez Behavior Barometer” is sent back to the parents or caregivers, as well as a parent handout describing what was covered during the session, and some helpful parenting tips.  Many times a parent-child activity is either suggested or created for additional parent-child engagement.

 
 

      The primary caregivers of these children are many times hopeless, resentful, wary, suspicious, self-doubting, and almost always embarrassed at the onset of therapy.  Coming from varied backgrounds, they all want their children to love them, and when they view their children through a different lens via therapy, they come to understand that “challenged children need their parents to observe and aim for (their strengths) in order to motivate the children into developmentally in-tune interaction, one tiny step at a time.”  (Shahmoon-Shanok, Clinical practice Guidelines, p.345, 2000.) It is as if BEST Buddiez resuscitates the caregivers with the hope for a healed relationship with their child and a more promising tomorrow.  It is our hope that BEST Buddiez is accomplishing just that, while transforming the parent-child relationship into a new perspective that will convincingly set a new course for life.      

Bibliography

 
 

Bowlby, J. (1969) Attachment and Loss. Vol. 1, Attachment.  New York:  Basic Books. 
 

James, B. (1996) Treating Traumatized Children:  New Insights and Creative

      Interventions (p.17) New York:  The Free Press.   
 

Grandin, T. (2000) Children with Autism:  A Parent’s Guide (p. XI), Bethesda: 

      Woodbine House. 
 

Greenspan, S. I. & Wieder, S. (2000) Clinical Practice Guidelines:  Redefining the

      Standards of Care for Infants, Children, and Families with Special Needs

      (pp.261-282). Bethesda:  ICDL Press.     
 

Powers, M. (2000) Children with Autism (p.70). Bethesda:  Woodbine House. 
 

Shahmoon-Shanok, R. (2000) Clinical Practice Guidelines:  Redefining the Standards of

    Care for Infants, Children, and Families with Special Needs (p. 345). Bethesda:  ICDL Press.   

 

Treating the Tender Roots of Foster Care:

Family centered treatment for young children in foster care

The science of early development and our understanding of the impact of early experience on later social, emotional, and cognitive development has grown dramatically in the past three decades…The current state of knowledge should impact how every system that works with infants and families needs to contemplate and address the needs of our youngest citizens and their families (Shonkoff & Philips, 2000).

Problem

The research base for early intervention is a broad footing upon which to build. How that structure is contemplated is debatable when it comes to building best practices for very young children in foster care. The clinical prognosis data held out to therapists working with foster care children is not reassuring, and when considering the developmental aspects of treatment of very young clients, the complexity of each case can be staggering. In part, the additional dilemmas face very young children placed in foster care who undergo a multitude of perceptual upheavals make these cases uniquely difficult:

  • Pre-verbal experience of trauma
  • A loss of their known world:   their primary caregiver
  • A loss of touch, affection, and a mode of soothing known only and specifically to the particular infant or young child and their biological mother
  • An extreme change of environmental smells
  • Changes in the decibel level of the environment
  • Many times, a loss of dialect or language use
  • Changes in complexity, color, amount of movement predictability, etc.

Their very sense of reality is challenged, and even if the on-looking professional climate views the change as needed and warranted, the impact on a baby or toddler is many times much more deleterious to the emotional development of the young child than is understood.   Consequently, the impact of foster care on very young children can many times become more negative in its impact than good intentions foresee.  

Due to the very critical phase of brain development in very young children, their emotional needs are particularly vulnerable.    There are stages of brain development described as “brain growth spurts” by Herman Estein (1978), a developmental scientist. He espoused that the complexity of the brain in infancy makes learning occur at an exponential rate in the first three years as opposed to later on in life.   For the past three decades, this information has infiltrated the academic literature, and has made an increasingly meaningful dent in the mental health literature.  

Yet, the consequence of foster care systems minimizing these concerns carries a price.   It is what Kotulak (1996) describes as the ultimate societal price paid out in violent acts. “The rising tide of abuse and neglect of children occurs during the critical period when children are developing what Harvard’s Felton Earls calls ‘moral emotions.’   These are emotions rooted in brain chemistry and are established in the first three years of life.” Trauma due to abuse and neglect is subjected to the impact of another type of trauma:   that of disrupted attachment.

John Bowlby (1988), the father of infant brain developmental theory and its relation to emotional long term development described four stages of development in the young child. Ultimately, Bowlby’s research drove his work regarding the “attachment theory” which has radically impacted early child mental health therapy at large.   At the far end of the continuum of problematic attachment patterns, DSM IV (1994) terms the diagnosis, 313.89 Reactive Attachment Disorder of Infancy and Early Childhood.   “RAD” as it has come to be known, “includes either one or both of the following:

  1. persistent failure to respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory Reponses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)
  2. diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachment (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures)”

Left untreated, the diagnosis has devastating social and emotional effects upon the family as described by Keck & Kupecky (1995):

  • Indiscriminate affection toward strangers
  • Lack of affection with parents on their terms
  • Little eye contact with parents
  • Lying about the obvious
  • Stealing
  • Destructive behavior to self, to other, and to material things
  • Abnormal eating patterns
  • No impulse controls, hyperactivity
  • Learning difficulties
  • Poor peer relationships
  • Lack of conscience
  • Cruelty to animals
  • Preoccupation with fire
  • Crippled ability to attach to any   human being

At least in part, these behaviors along with others result in alarming statistics for children raised in foster care across the nation (Ademec & Pierce, 2000):

  • 37% of children in foster care receive special education services
  • 27% of children under 6 years old are treated for respiratory disorders
  • 20% children under 6 years of age are treated for chronic skin disorders
  • Less than half of children raised in foster care finish high school, which puts them at a higher risk for drug abuse and teen pregnancy
  • Approximately 80% of children raised in foster care receive a mental health diagnosis
  • Over half of children raised in foster care end up unemployed as adults.

While the public is becoming much more aware that a baby’s brain has a type of window of opportunity like none other to build synapses and hard wiring that will last a life time, many times, these same issues pale when considering reform for the very young in foster care.   In fact, the wealthy public, the educational arena, and even celebrity concerns for early cognitive stimulation overshadows the need for a more intense focus on emotional well-being of infants in foster care.   It is time for a call for money to be spent, and time to be spent, and treatment to be targeted for these, the most vulnerable of our society.   

Paradigm Shift

Many well-meaning professionals could extrapolate this information regarding early brain development as a need for educational early intervention and stimulation, met with early day care placement.   Yet the most pronounced difficulty from the foster care unit professionals in Wake County, North Carolina was described unilaterally:   the foster parents have incredible challenges with the stabilization of their foster children in preschool placement.   Due to physically aggressive behaviors and severe tantrumming, many children undergo multiple extrusions from their daycare and preschool settings, which continues to subject them to disrupted relationships.   Many children placed in foster care, (even those placed in a substantially more stable home environment,) find themselves expelled from their day care environment because of their maladaptive behaviors.   This becomes yet one more upheaval in their little lives.  

In a system where the foster caregiver typically works full time, the plight of the very young takes on an even more difficult task. For many foster care parents, they simply cannot keep their jobs when their foster child is being asked to leave school, and so the threat of a failed placement looms for these behaviorally challenged preschoolers.    In an attempt to find permanency for children within a year, it is reasonable for the state to place emotional needs in second place to a workable placement.  

Unfortunately, the whole concept of permanency leaves much to be desired, in terms of the impact on the socio-emotional well-being of the young child.   Permanency is not the totality of what young children need and want.   Yet as far as the social norm for foster care is concerned, it is stamp of approval sought by county social workers, guardians ad litem, attorneys, judges, and case workers.   Whether or not the children are attaching to the foster parents remains secondary on the list.   Whether the foster parent is keeping them safe is understandably the primary concern of the child welfare arena.   And the biological parent has their own list of priorities as well:   clean drug screens, successful attendance at parenting classes, suitable housing, stable employment, etc.  

Yet with all of the hoops that have to be negotiated by reluctant biological parents, little attention is given to the level of attachment and the actual observed parenting skills that they have demonstrated.   The permanency planning paradigm may make sense theoretically and financially for the short term, but renders little assurance for the birth to five year olds in the foster care system.    As a result, those who are re-united with their family are at high risk for re-entry into the system.         

Proposed Treatment

There are many models for improving the attachment between child and parent.   The Child Mental Health Initiative (CMHI) in Raleigh, N.C. became very interested in these models as the roster of referred children involved in child welfare grew.   CMHI is one of the most frequently used mental health resources in the public sector of Wake County for birth to five-year-olds with serious socio-emotional problems.   Because of the alarming 40% of enrolled clients had some history of involvement with child welfare over the last 5 years, models were sought for efficacious treatment of these young children and their families.   Two models seemed particularly useful.

The Circle of Security Project (Marvin, Cooper, Hoffman, & Powell, 2002), necessitates strong family involvement and their training protocol was earmarked by the following objectives for the parents to:

  1. grow more sensitive and responsive to their child’s signals
  2. increase their ability to consider their own behavior as well as the child’s behavior along with their thoughts and emotions about the attachment building interactions.
  3. to consider experiences in their own backgrounds that impact their parenting styles.

The Circle of Security proponents start with training the parents in a group so that they can become familiarized with their own history of security as it developed for them as young children.   The parents watch films, and learn to rethink the cues from their children that in the past have caused them to grow frustrated, angry or distant, resulting in all the more difficulty with building a secure attachment with their child.   The strategies that are utilized for parents experiencing difficulties with their preschooler    are based upon the understanding of what theorists have identified as four patterns of attachment (Marvin & Britner, 1995):

  • The secure child-autonomous parent
  • The insecure, avoidant-dismissing
  • The insecure, ambivalent
  • The insecure, “disordered” pattern.

The parents in this model undergo a 20-week intervention designed specific to the needs of their pattern of relationship with their child.   Pre and post assessments include videotaping the Strange Situation, the pre-school version (Ainsworth & Wittig, 1969) to determine attachment patterns.   Additionally, the parent is given some tasks to complete with the child and the parent-child interaction is taped.   Immediately following this interchange, an interview with the parent follows.   The parent is interviewed and standardized assessments are administered that consider the child’s behavioral problems, including anxiety and depression.   Standardized tools measure the parents’ stress level and stressful environmental factors.   The proponents of Circle of Security state that as the pattern of attachment and communication shifts within the parent, the child’s level of attunement and relational reciprocity shifts as well (Marvin et al, 2002).  

Another model, which will be referred to as the Tulane Model was pioneered 16 years ago by the vice chair of the Department of Psychiatry at Tulane in New Orleans.    Dr. Charles Zeanah, director of the Infant Team at Tulane, has utilized techniques and strategies based in attachment theory, (Larrieu & Zeanah, 1998).   Their team works with children under 48 months who have been placed in foster care, their biological parents, as well as their foster care parents.   Videotaped interviews and additional instruments utilized in the Tulane Model guide the therapy delivered to the biological parents to re-organize their parenting strategies, and to enhance the attachment patterns that they have historically utilized with their children.   

Hence, the treatment ensues with both sides of the family, both biological and foster, to maximize the possibility that the young child is able to build attachment with at least one side of his/her significant familial world.   Certainly, the work with the biological parents increases the likelihood of the bio parents exhibiting healthier parenting skills.   In fact, Zeanah and his staff (Zeanah et al, 2001) found that there was a 50% decrease in recidivism in additional neglect/abuse charges by the biological parents who received treatment through their program in comparison to a control group.  

In Raleigh, North Carolina, there is an effort underway to replicate these principles.    It is designed to turn the paradigm around from “sufficiency” to best practices, best services, and best care provided to the very young in child welfare and their families. The program is housed within the Child Mental Health Initiative of Learning Together and is called “BEST Care Kidz.”   While BEST Care Kidz is in its infancy, the practice of the principles is not.   BEST Care Kidz is a sister program to BEST Buddiez, which is the treatment program for preschoolers based upon the prevention themes in literature of Boundaries, Empathy, Self-esteem, and Thinking.   Based upon these prevention principles, the models outlined above are embedded in its philosophy.  

The program has melded the efforts of several community agencies to build a collegial network of referring professionals.   Through this fluid network of referrals, young children in the child welfare system identified with behavioral or emotional difficulties are being referred to the program to stabilize their behaviors.   Treatment includes in-school and in-home play therapy, in which foster parents are equipped to play therapeutically with their children.   BEST Care Kidz has established internships from area universities to provide wrap-around services to these very needy families.  

Already, the “fit” for these principles being utilized on a lesser scale has been encouraging.   Even pre-verbal clients, or those who have endured abuse are treated through SIP therapy (Solution-focused In-role Play Therapy,) and many times group therapy is utilized through BEST Buddiez groups to practice pro-social skills to increase the possibility of a successful placement in preschool, (Terrago, 2005).     During these groups, foster care parents as well as biological parents are invited to attend parenting workshops held simultaneously with the BEST Buddiez groups.  

Work with the biological family is certainly the most intense work.   During visitations with their child, the interactions are videotaped and later processed with the parent to improve the pattern of attachment.   SIP Therapy principles are utilized and modeled for the biological parents during these supervised visits.   These techniques and strategies and are utilized to help the parents build a deeper bond with their child.   These include, but are not limited to:

  • Learning to be sensitive to the child’s cues
  • Establishing calm competency at all times with the child
  • Identifying the child’s comfort zone:   what activity is the child most easily engaged in play, and how does the child initially like to play…functional play, emerging pretend skills, or elaborate pretend skills
  • Following the child’s lead initially
  • Tracking what the child is attempting to accomplish
  • Imitating the child’s behaviors
  • Reflecting the level of comfort with physical proximity
  • Noticing and being sensitive to the level of the child’s eye contact
  • Allowing the child to “work through” the anger by reflection of feelings
  • Joining with the child:   taking on the role of supporter with the child…expressing verbally the sharing of the experience, and as much as is possible, utilizing bodily presence.  
  • Slowly introducing pro-social skills such as   nurturance and rescue into the play themes of the child
  • Practicing the preparation of the end of the play session, as a means to build resistance to gratification frustration.  

Certainly, there is an art in this therapy, and many behavioral parenting skills are introduced as therapy progresses.   Allowing the creativity of play and imagination take precedence with the child during therapy can take therapeutic alliance to a whole new dimension with a two, three, or four year old.   Helping foster parents to learn how to become their child’s safe haven is a building block to other attachment building skills.   Playfulness is pivotal to the therapy, so as to help the foster parent feel differently toward the child, and to help the child feel differently and behave differently with the foster parent.

The biological parent piece is sometimes the part that is grossly overlooked when working with latency aged children, but is absolutely imperative when working with birth to five year olds.   The parents in this program are encouraged to attend their court ordered parenting skills classes, but the more complex the case, the less apt these classes will be adequate to address the deficits of parenting the child.   The biological parent component of treatment includes teaching and modeling attachment exercises through play with their child.   Ultimately, the program helps parents to identify cues that their child emits, utilizing “the language of the child,” as Dr. T. Berry Brazelton expresses in his “Touchpoints,” (1992) in a non-judgmental fashion.

BEST Care Kidz is still in its infancy, built upon the evidence based practices from the Circle of Security literature and the Tulane Model, and it is already witnessing encouraging outcomes with more children being referred and treated as the successes grow.   While BEST Care Kidz does not have the monetary reserve to warrant extensive assessment tools and video taping, the Medicaid billable services as described above are quite replicable for other non-profit programs serving very young children.   It is not just for the moment that these fragile children are treated, but the development of their little brains is dependent upon new and research-inspired practice.   They are the tender roots of foster care, and they call out for counselors everywhere to treat them with new-found energy, compassion, sensitivity, and innovation that their tender state warrants.  

References

Adamec, C. & Pierce, W. (2000).    The Encyclopedia of Adoption, 2 nd edition, excerpt available on line at www.encyclopedia.adoption.com

Ainsworth, M. & Wittig, B. (1969).   Attachment and exploratory behavior in one year olds in a strange situation,”   B. Foss, ed., Determinants of Infant Behavior, vol. 4.    London: Methuen.

American Psychiatric Association (1994).   Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, DSM-IV.   Washington, CD:   American Psychiatry Association.

Bowlby, J. (1988).    A secure base:   Parent-child attachment and healthy human development.    New York:   Basic Books.

Brazelton, T.B. (1992).   Touchpoints:   Your Child’s Emotional and Behavioral Development.    Reading, MA:   Perseus Books.

Epstein, H. (1978).  Growth spurts during brain development:   Implications for educational policy and practice," in Cahl and Mirsky, eds., Education and the Brain.   Chicago:   University of Chicago Press.

Kotulak, R. (1996).   Inside the Brain:   Revolutionary Discoveries of How the MindWorks.   Kansas City, MO:   Andrews McMeel.

Larrieu,   J. &   Zeanah, C. (1998).   Intensive intervention for maltreated infants and toddlers in foster care.   Child and adolescent psychiatric clinics of North America, 7, 357-71.

Marvin, R. & Britner, P. (1995), Classification system for parental caregiving patterns in the preschool Strange Situation.   Unpublished classification manual.

Marvin, R., Cooper, G., Hoffman, K., and Powell, B. (2002).   The Circle of Security project:   Attachment-based intervention with caregiver-pre-school child dyads, Attachment & Human Development, Vol. 4, 107-124.

Terrago, R. (2005) BEST Buddiez:   A Programmatic Innovation in Early Child Mental Health Treatment for Physically Aggressive Preschool Children, Vistas 2005, available online at www.counselingoutfitters.com/vistas

Shonkoff, J.P. & Meisels, S.J. (2000).   Handbook of Early Childhood Intervention,2 nd edition.   New York:   Cambridge University Press.

Zeanah, C.H. Larrieu, J.A., Heller, S.S., Valliere, J., Hinshaw-Fuselier, S., Aoki, Y. &   Drilling, M. (2001). Evaluation of a preventive intervention for maltreated infants and toddlers in foster care.   Journal of the American Academy of Child and Adolescent Psychiatry, 40, 214-221.

 

Name:  Rita Terrago
Title:  Director of Child Mental Health, LPC, Infant Toddler Certification
Company:  Jacob's Ladder childhood therapies
Address:  8928 Hwy 70 west, suite 100
City:  Clayton
State:  NC
Zip:  27520
Office:  919-550-7397 Ext 24
email:  rita@jacobs-ladder.ws
Bio:  WATCH Participant. Rita Terrago is the director of the Child Mental Health Initiative at Jacob's Ladder childhood therapies Clayton N.C., where her team treats birth to five-year-old children with very serious behavioral disorders which have included Autistic Disorder, PTSD, Psychosis NOS, Bipolar Disorder, ODD, and attachment difficulties so frequently experienced by young children. Rita was the coordinator of a sexual abuse and awareness program for Devereux, Florida Network in Orlando, and has worked in mental health fields for over 30 years. She trains and supervises interns and therapists new to the field of young child mental health, and conducts consults in area wide childcare centers. A distance doctoral student of Kent State University’s Counseling and Human Development Services department, Rita presents at area, regional, and national workshops and conferences regarding her work with pre-school children and their families, while completing her dissertation in Counseling and Human Development.