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Article 11

BEST Buddiez

A Programmatic Innovation in Early Child Mental Health Treatment for Physically Aggressive Preschool Children

Rita J. Terrago

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“I have autism…I was lucky to begin early educational intervention when I was 2 1/2 years old. Back in 1949 most children with autism were sent away to institutions. At age 2 1/2 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, PhD (2000)

A pilot program at Learning Together in Raleigh, NC, incorporated research-based practices and community professionals’ expertise to work with birth to 5-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 3- and 4- 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 ongoing therapy after discharge. The other 15% upon discharge had significant mental health issues necessitating ongoing care from a child psychiatrist or developmental pediatrician for medication 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. Twenty-two percent 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 that 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 (SIP), as we have coined it, characterizes the BEST Buddiez program, which is largely based in Stanley Greenspan’s Floor Time play therapy techniques. Greenspan, founder of the developmental, individual difference, relationship-based (DIR) intervention approach, pioneered Floor Time with children diagnosed with autistic disorder (Greenspan & Wieder, 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 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 (Greenspan & Wieder, 2000), and the main tool is the therapist him or herself (Powers, 2000). Solution- focused in-role play therapy utilized in BEST Buddiez is characterized by active play sessions, which occur on the floor. Other characteristics are as follows:

• The relationship built between the therapist and the child becomes 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 nonjudgmentally follows the lead of the child. If a particularly violent child starts out by “killing” the characters that he or 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 his or her 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 reenacting these horrors (James, 1996). Fortunately, these episodes call upon a rescue theme very nicely, which can meet the emotions 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 or 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 or 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, 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 these principles, bringing together up to six boys or girls, 3 or 4 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 1 1/2 to 2 hours, and the entire series consists of eight 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, for example, train play, dinosaur world, or emergency world, barnyard day, Hawaiian Luau day.

• 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 just outlined 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 of art therapy, dress up corner, housekeeping, and the play world of the day that encompasses all of these in some way.

• A nutritious snack reflects the play theme of the day, whether it be a freshly 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, 2000, p. 345). 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.