Good respite can save a placement. “The healing program necessary for challenging children can be compared to a three legged stool,” according to William Goble Ph.D. With Therapy, Parenting and Respite, each being a necessary leg to achieve family balance! A good respite provider can be more important to the family and child then the therapist or the case manager! This chapter is written to give options to mothers whose children do NOT have a healthy attachment to them. Respite can take several forms.
When day care is necessary the daily child care provider is an integral part of the family. The day care provider interacts with the child in lieu of the mother’s availability. Therefore there needs to be the same amount and the same quality of bonding interactions with the day care provider that the child would be having with the mother if the mother were able to stay home from work and do it. The information in this chapter is not directed at day care situations where children with a healthy attachment to their mother go during the day when their mother is not able to take care of them herself.
Babysitting as Respite
Normal respite is similar to a babysitter, used when the family wants to go somewhere or do something and it is not appropriate to take the child. Babysitting would be most appropriate for a normal, healthy child with a normal, healthy relationship with his mother and normal, healthy behaviors and boundaries. There is nothing particular in the child’s behavior creating a situation that the parents would need to be away from, it is just that they are going somewhere it is better the child not go. For example, when the mother has a doctor’s appointment, there is a school meeting or the parents have a date night the child goes to the respite home and does whatever the respite provider’s family is doing. He enters the family like a guest and participates in the family activities.
Therapeutic Respite - Defined
Therapeutic respite is scheduled regularly for the family to maintain its collective sanity and for the parents to maintain their couple relationship. It should be scheduled one afternoon or evening each week and one long weekend a month for children over four years of age. The therapeutic respite provider should be trained to provide the same structure the parents are using at home. They need to be supportive of the parents and encourage them to seek regular respite in order to take care of themselves and give themselves time for rest and renewal.
The goal of the provider is not to interfere in the budding relationship of the mother and child by nurturing the child. All nurturing must come from the parents during this time of creating a relationship and healing one that is damaged. Loving touch, sharing of sugar, hugs and loving eye contact are not provided by the respite provider. High five’s and a pat on the back are appropriate and encouraged. The child in respite must not have more fun with the respite provider then with his own family as this creates a competitive edge between the family and the respite provider. The care provider must remain vigilant to avoid triangulation created by the disturbed child.
Therapeutic Motivational Respite – Defined
Therapeutic respite is regularly scheduled to give the family a break from the day to day pattern of interacting with the child. Therapeutic motivational respite (TMR) is set up when the child has regressed to such a level that a change of venue is needed in order to motivate him to “shift gears.” It is usually easier for a child with a disturbed attachment to do things correctly for others, rather then his mother. TMR gives the child an opportunity to practice those behaviors he needs to demonstrate at home but has not been able to due to the fear of attachment. TMR is a safe place for the child to shift mental gears, get back on track and return home with positive skills. TMR should never be punishment or punitive. It should always be opportunity.
Therapeutic Respite to Help Healthy Family Members Stay Healthy
There might be times when the child’s negative behavior in the past is part of the decision to not take the child with the family. Many parents and families find they have been forced repeatedly to stay home from numerous fun events and activities the family would like to engage in. Because the child’s public behavior makes participation impossible they all miss out on fun times. Giving the child the ability to sabotage a family’s fun times is not good for the family or the child. It leaves members of the family resentful that they can no longer do what they used to do, go where they used to go or have the fun times they used to have. Large numbers of families with children with challenging behaviors have ceased to go to the movies, extended family gatherings, out to dinner or to church because they could not trust the child with negative behaviors to cooperate and not create a scene. Resentful parents and siblings do not create the best environment for a child to heal. Healthy siblings must be helped to stay healthy. The family must devote as much time to keeping healthy siblings healthy as they spend in finding ways to heal the traumatized child. Healthy siblings must experience that their emotional and mental health is as important to the family as the emotional and mental health of the child with challenging behaviors and emotional states. They must experience that they are not the sacrificial lambs for their sibling’s disability. Without that clear message to all of the children there is little reason for the child with attachment disorder to heal. Why should he heal if, by remaining uncooperative and defiant, he can remain the center of the family’s attention and focus? Why should he heal when he can use his ability to control the family and bring everyone down with him? Respite gives the child with behavioral challenges and the healthy children the message, “There is a benefit to being fun to being around.” The power of pathology needs to be curtailed, not reinforced.
One of the tasks of the parents is finding ways to hang in there with their child for the long haul. It is imperative therefore, that parents take good care of themselves and the healthy siblings so they can continue the high level of commitment without getting burned out to the point where they ask to have the child removed from their home due to exhaustion! Exhausted parents do not have access to their own best judgement and problem solving skills. When parents temporarily lose the “love light” in their eyes when looking at their child, they need a break in order to regroup and bring the child back into their arms with joy. Children know when their presence is not welcome and they cannot thrive in that knowledge. Better for the parents to be honest and admit to themselves and their child they need temporary relief then to have everyone sink into resentment. Without respite the mom of a child with attachment disorder does not have any time to get her energy and commitment renewed and recharged. She can feel isolated and alone. Without respite the mom’s sense of being defeated and overwhelmed puts her in the position of having to disrupt the relationship in order to have a happy, healthy life. It is not helpful to put a mother in the position where she has to choose between her child’s mental health and her mental health. Both must achieve a balanced mental health or both will suffer.
At the same time it is not good for the child to have that much power over the rest of the family. It is not healthy for a child with emotional and behavioral difficulties to be able to control what others do and don’t do, where they go and where they don’t go. Being able to control others with negative behavior does not diminish the negative behavior it increases it! It does not increase the child’s ability to attach, it decreases it; children want to mimic and be like the strongest people in their environment. If that strongest person is the child with the ability to stop family activity in its tracks then that child does not have anyone to make a safe attachment with. According to Foster Cline, MD, “The child will internalize the parent of perceived power.” If he perceives there is no one more powerful then he is then he will internalize his own rage and not learn to trust others.
In these circumstances it is important that the family be able to engage in fun activities without one child sabotaging them, so the child is taken to therapeutic respite. Respite can be enjoyable for the child or not. That is not what is important as the child is not in respite in order to punish him. What is important is that the family has, temporarily, placed its need to have fun times together ahead of the child’s desire to participate in this particular family activity. When the family returns to pick the child up and the child says, “I had a great time!” the best response is, “Great, we did too. I am glad we all had a good time.” If the child says, “I hated being left behind,” then the response is “That is too bad. Maybe you can work on that so it doesn’t happen again.” If the child asks, “Why do I have to go to respite?” The assumption is that good parents and therapists have already explained to the child the difficulties the child’s behavior presents to the family. Generally, the child knows exactly what he/she has done to warrant being sent to respite. Therefore, by this time the less said the better as the more parents talk the less children listen! Children must have numerous opportunities to do their own thinking and figure out for themselves why they went to respite when the family went to the movie. When a child examines his own behavior and determines for himself why he was left out of an activity he is less defensive and argumentative and more open to change. An appropriate response therefore might be chosen from among the following examples: Lovingly and without sarcasm, the parent can say, “Hope you figure that out,” “That is a great question to ask your therapist,” or “That is a very good question. While you are in respite I want you to write a paragraph on that.” With the help of a therapist to help the child sort out why the family could not take him along with them, the child may figure it out sooner rather then later.
The goal of Therapeutic Motivational Respite is to not need it!
Many children with attachment disorder have been abused and traumatized beyond what most adults could stand. In order to survive the child had no choice but to find an inner strength to go on in the face of such horror. They have developed an inner resistance to the promptings and proddings of loving parents as they believe to capitulate is to die. Survival in the past depended on their maintaining pseudo control in the face of inhuman abuse and/or neglect. They are not going to now turn control over to well meaning but, to them, unnecessary control by unnecessary parents. The ability of a child with attachment disorder to spiral down in continued attempts to withstand being controlled by their parents, even to their own detriment, is legendary. Often a child with attachment disorder will hurt himself if it means hurting his parents or evading parental ability to exert any control over them…..a control that is seen as life threatening by the child. That being the case, many parents are out of their league when it comes to finding a way to meaningfully impose any measure of discipline with the child. The child’s negative behavior, when he senses a need to trust the parents, will escalate. In response the parent often escalates. Whenever this downward spiral begins the child and parents need a break from each other to regroup and rethink. The parent’s battle for the child’s heart is not lost, but everyone needs to take a step back and seek additional help before going forward in a manner that could have disastrous results. The child needs to be in an environment where he can ask the questions about whether or not his behavior is truly worth it. The parents need to be removed from the daily crisis of handling the behavior to calm down and seek help in finding other ways to approach managing the child’s behavior. When a child’s ability to test the limits outlasts the parents’ ability to positively respond a respite provider can step in and bring a temporary relief from the overwhelming feelings and positively change the parent and child dynamics. Respite to the rescue!
Children with attachment disorder see that part of their task is to “get” the adult.
The adult’s job is to not “get” got!
One way many adults “get got” is to become enmeshed with the child’s pathology. Rather then helping the child confront their fears of abandonment and helping the child through those fears they walk on eggshells to avoid a confrontation. They have more respect for the child’s pathology then they do for the child’s ability to get well.
“You cannot push a river upstream” is an old Chinese proverb that works as well with water as with children. Healthy children benefit from occasionally being given something they desperately want, even when it is not good for them, to let them experience for themselves how it works out. The principle of giving a child what he thinks he wants and then letting him think through the negative consequences is used repeatedly in the real world and can be artificially applied using the principles of paradoxical interventions. For example, a child does not want to study for his math test. The parent cannot make him study. Forcing a child to memorize math facts is impossible. In actuality, attempting to force a child to do something that is out of the parent’s control has a tendency to make both the parent and the child very angry at each other. The most a parent can do is place the child in a situation where the child can become thoughtful about studying. The logical consequence of not memorizing math facts falls into place quickly when the child fails the math test and is then kept in from recess by the teacher in order to work on them or is not allowed to accompany the class on a field trip as his grades are not sufficient. Giving permission for the child to not study takes the parent out of the control battle……a battle the parent cannot win anyway. Thus begins the awakening in the child of the principle, “You can have short term gain (play instead of devoting time and effort to study for the test) and long term pain (flunk the test and have to redo the class work) or you can have short term pain (stop playing and study) for long term gain (good grades, field trip, recess, etc). Generally life does not offer both short term gain and long term gain. The adage is “No pain, no gain.”
These principles can be applied to determining whether or not respite is appropriate for a child with a disordered attachment. The argument is sometimes made that to separate an unattached child from his parents for the purposes of respite is further traumatizing and recreates feelings of fear, rejection, abandonment and being unloved and unwanted. When appropriately applied, however, the exact opposite occurs!
When a child is angry, verbally abusive, assaultive and in numerous other ways demonstrates with every breath that he hates being in the company of his mother and is allergic to the sound of her voice is the perfect time to give him exactly what he thinks he wants and then let him become thoughtful about the consequences. It gives the child an opportunity, in a safe environment, to play out his inner desires to be away from his mother and to experience how that feels. He then has an opportunity to become very thoughtful about whether or not he truly does want to kill his mother, run away, destroy everything she owns, hurt her other children, throw the food she lovingly prepares or call her a stream of filthy names. Without the constant pressure of the presence of his mother calling him into a loving relationship he can step back and explore what he really, truly desires, now that he is in a position to choose. Most children with disordered attachments have been placed without their permission or consultation in a family that was chosen for them. At some point the child must be given the opportunity to choose his family in the same way the family chose him! Appropriate and well executed respite empowers the child to choose his family. Instead of always feeling that his life is out of his control, from his abuse to his neglect to his abandonment to his institutionalization…….he now has the power to choose for himself what his life will look like in the future.
The fear of placing a child in respite often has less to do with confronting the child about those behaviors that he engages in (an attempt to push his mother away) and more to do with the fear of the therapist and the mother that once the child is in respite he won’t choose to return home!
When respite is poorly done by ill trained providers that fear can become a reality! However, it is not therapeutic respite that must be avoided but respite that undermines the love of the mother and family that must be avoided! Just as it is not open heart surgery that must be avoided if necessary, but poorly executed open heart surgery by an inexperienced, untrained surgeon. A poorly trained surgeon can kill the patient. Therapeutic respite that is not well thought out can kill the child’s relationship with his mother. Conversely, therapeutic respite that is planned and implemented with the clear goal in mind of awakening regard in the child for his mother can save the placement.
Goals of TR and TMR
The goals of both Therapeutic Respite (TR) and TMR are to maintain the child in a tightly structured, controlled environment where they can practice being respectful, responsible and fun to be around in a manner similar to what they would be experiencing if they were at home. “It takes a village to raise a child.” In the case of children with severe emotionally and behaviorally disturbed behavior it is unfair and unwise to expect parents who signed up to parent a child to manage the full extent of that child’s behaviors and emotional states by themselves. Most parents who adopt or agree to do foster care do so with the understanding they will have support through the difficult times. Most parents, no matter how well trained and how well meaning, are not capable of turning their homes into one man or one woman 24 hour residential care facilities. Even workers in child care centers get a break! Society as a whole has to shoulder some of the responsibility of training the child as society as a whole will bear the brunt of the pain if the child does not learn. Thus, the need for therapeutic respite and TMR that is beneficial to the child and family will ultimately be beneficial to society as well.
Therapeutic Motivational Respite – When it is used
This form of respite is more difficult to find as it is difficult to provide. TMR is used when the child with disordered attachment is actively pushing his family, especially his mother, away. The goal is for it to be needed less and less until it is not used at all. After all, part of the plan of having a child is to have the child live with the family until he emancipates. Parents need to develop the skills to manage whatever behavior the child exhibits in order to demonstrate to the child they are strong enough to keep him safe and therefore are strong enough to be his parents. That said, there are times when TMR is necessary for both the family and the child’s growth and healing.
When a child refuses to go to his room or in other way makes it clear that he does not have to do what he is told, then he, not the parents, has taken control of the home and the environment. Anytime the home is out of the control of the parents the family is not safe. The parents are not safe, the other children are not safe and the child who has wrested control of the home from the parents is not safe. Anytime the home is not safe and the parents are not in charge of the environment then the children “detach”. They are not going to place their lives in the hands of someone who is not strong enough or wise enough to protect them. Going to the room, therefore, is a means for a child to remain in the home while he gets himself under control. When he demonstrates that he is not able to keep himself and the family safe by removing himself from the immediate vicinity of the family then he must leave and go to TMR. When he persists in staying where he is in the home, refusing to go to his room and disrupting an activity the family wants to engage in but can’t as long as he is undermining it then he must go to TMR.
When the child becomes physically aggressive and compromises the safety of other members of the family and/or himself and refuses to go to his room to calm down then he must go to TMR. When the child carries on in uncontrollable temper tantrums, ruining the family environment for everyone else and refuses to go to his room to conduct his tantrum then he must go to TMR. Violence in the home must not be tolerated. Whenever a child attacks his parents or siblings physically and demonstrates enough strength that the potential is high for someone to become injured, the child must go to TMR. When a child becomes aroused and getting him to respite becomes dangerous have the respite provider pick the child up after school so an adrenaline pumping scenario at home is avoided.
Another time TMR is useful is when the child is expelled or excluded from school. Children with attachment disorder scarcely allow their parents to give them any direction during the normal course of living in the home together. It is almost impossible then for parents to exert any meaningful control over what happens in school. Rather, if a parent is unwise enough to intervene at all in any way in the school setting the child will use it as an opportunity to say very clearly to the parent, “You can’t make me attend school. You can’t make me succeed in school.” The problem is that the child’s message is absolutely correct. School issues are one of those where the child is in complete and total control. That must be acknowledged and the wise parent then steps aside whenever the occasion arises for the child to refuse to cooperate at school on any level. If the parent must not get involved in the child’s choice to not cooperate at school to the point of being suspended or expelled then it is also good for the parent to not get involved in getting the child back into school. The child got himself kicked out. The child must get himself back in. This is best done through a TMR provider so that as soon as a child is removed from the school, the child does not come home to be a thorn in his mother’s side, but goes directly to TMR. The message to the child is “It looks like you need time to develop life skills that do not require an education. That is fine. The world always needs people who can wash windows, do yard work and clean.” This message must be communicated with actions, not words. If words must be used one choice might be, “You can have a strong education or a strong back. Your choice. Good luck.” (Again…… tone of voice is EVERYTHING! Anything said in sarcasm or anger loses all positive motivation for thoughtfulness.)
Another use for TMR is when the child refuses, either overtly or in a variety of passive yet aggressive ways, to get ready to go to school or to another planned activity, thus forcing everyone to be late. The child has effectively taken control of the family environment. There is no time to give a child an opportunity to get back on track by going to his room. So, ready or not, when the family is ready to leave the child gets in the car. Instead of going with the family the child is dropped off at TMR. Generally this happens only a few times before the child realizes that mom is meaning business without being mean. Mom does not reason with the child, cajole the child, threaten the child or get angry! Ideally the parent would simply and calmly state to the child that she knows he is just not able to get ready by the time everyone else is ready and that is OK. However, in order for everyone else to be on time, then the child can just get in the car as he is. The parent then scoops up the necessary items the child will need to complete getting ready, puts them in a bag and takes them out to the car. It might be the child’s clean clothes, toothbrush, comb, shoes, etc. Once the child is in the car the parent drives the child straight to respite. When the family has gone where it set out to go then the parent can return and pick up the child. Having a plan such as this in place, energizes the parent and gives her the realization that she does not have to stand by powerlessly while the child sabotages family activities. Instead of dreading, nagging or prodding a child to get ready, the parent anticipates the problem behavior, knowing she is going to manage the behavior appropriately. That knowledge allows the parent to stay calm and not get upset. Pathology is fed by the parent’s anger!
Running away is another opportunity for the child to go to TMR. The message from the parent is, “I can love you no matter where you live. If you are unhappy living with me then I want to find some place else for you to live.” Parents must not get into a power struggle over where the child will live. The child, particularly older children, must choose to live at home. Generally the parent does not take the child to TMR. It is far more valuable for someone else to chase down or find a runaway. The best way to insure the child runs away again is for the parent to demonstrate to the child how alarmed and invested she is by going after him. It is far better for social services, the police or the TMR provider to go in pursuit and take the child to TMR where the child can have the opportunity to rethink his choice.
A child who makes false allegations of abuse is also a good candidate for TMR. This is to keep both the family and child safe. The message to the authorities is, “If the child is telling the truth then he is not safe with me. If the child is not telling the truth then we are not safe with him.” Either way he will need to go somewhere else temporarily until it is straightened out. An extraordinarily destructive way of letting people know they don’t matter to you and you don’t want to matter to them is to falsely accuse them of abusing you. While there are certainly instances where foster and adoptive parents are guilty of neglect and abuse, we believe those instances are far below the national norm due to the homestudy process and contact with social workers that foster and adoptive families experience. We believe the vast percentage of abuse and neglect occurs at the hands of birth family members. It is so common that it might make the local news if it is bizarre and news-worthy enough, but only in extreme situations does it make the national news. However, if a foster or adoptive family is found guilty of abuse or the news finds out it is being suspected of abuse, it becomes a headliner in and out of the community. Why? Because it is so rare! Yet time after time a family demonstrates to a local agency after a rigorous homestudy process that they are stable and capable of making good parenting decisions only to be accused of abuse by a child that has a known history of lying. Remarkably, the child is believed! Having the child go to TMR to weigh the advantages and disadvantages to him of his decision to falsely charge his parents with abuse is an excellent use of his and the family’s time. It gives the child an opportunity to examine for himself whether living in his family is such a bad experience that he needs to go to this length to get out of it. It gives him an opportunity to examine whether or not exchanging his loving family for a TMR home was such a good idea after all. It is not a form of punishment for filing charges of abuse. It is instead, a period of time when those in authority can keep the child safe while reviewing the validity of the charges. One thought for the parents to keep in mind, “If the child is telling the truth then the child is not safe with the parents. If the child is not telling the truth then the parents are not safe with the child. Either way the child needs to be living elsewhere at least temporarily.”
Goals of Therapeutic Motivational Respite
Obviously the overall goal for any respite situation is for the child to return home and want to do what is necessary to stay there. So, one goal is for the child to practice the skills in respite that are required for him to live at home. There are numerous goals that contribute to a child moving in that direction. If the child is in TMR because he is uncooperative and defiant over tasks to the point where the parent is exhausted by his care then practice becoming less defiant and more cooperative is his task. If the child is in TMR because of his numerous temper tantrums then controlling his emotionality becomes the task. For children who spend their days chattering nonsense and wearing out parents’ ears, the task of practicing good quietness, not interrupting and being unobtrusive or, utilizing a paradoxical technique, the task of sitting in a chair and chattering when instructed. If the child is in TMR because he refused to go to his room then he must practice going to his room. In other words, whatever the child is doing that is exhausting his family and overwhelming his parents to the point where they need a break in order to recharge their batteries, is what the child needs to practice in TMR.
How is this done? If the child is not willing to manage their behavior in their own home, why would they do it in someone else’s home?
Typical of a child with disordered attachment is the ability to be superficially charming and compliant with strangers. They can appear alarmingly charming and loving. It is important for a TMR provider to not misinterpret this, but rather use it to their and the child’s advantage. Often a child’s initial ability to be cooperative and endearing is derisively dismissed as “the honeymoon.” It is viewed as a trick of the child to encourage an adult to let down their defenses so the child can later take advantage of them. Taking this view and doing what is classically called a “reframe,” what if, instead of seeing it as manipulation of the child it is seen as a child’s best effort at showing the good in himself? This would change the mindset of both the parent and the TMR provider. Remember…Children behave the way they behave because they think the way they think. And……..What adults believe about a child’s behavior determines what they will do about the child’s behavior. “Honeymooning” behaviors are welcome, with or without the child’s intent, as they are wiring their brain in the right direction!
With these thoughts in mind then it would be easy for the parents and the TMR provider to interpret the child’s initial positive behaviors as examples of the inner child shining through. It is important the TMR provider not say, “Look at how well he is behaving for me. Mother must be doing something wrong that he doesn’t behave this well for her.” That would be an insult to the good will, efforts and experience of the mother, which is exactly the opposite message the exhausted mother needs at that point. To have her experiences and negative interactions with the child over a period of months and years dismissed by someone who has known the child only a few hours or days is demeaning to the mother and is not helpful to the child. It gives the child the message that there is nothing wrong with his behavior but a great deal wrong with his mother. He chooses to believe that she brings out the worst in him. If there is nothing wrong with him, he can reason, then there is no reason for him to change anything. The child erroneously believes it is up to his mother and family to change. They must be more accommodating to his unwillingness and inability to be a reciprocal member of the family.
A far better message to the child when he acts in a manner vastly different then what he manifests in the home is to confirm for him that he has goodness inside of him and with practice he can show that goodness, not only to the TMR provider, but to his family. Both the parent and the TMR provider can thank the child for letting them see how much fun he can be around as sometimes they lose track of that when just observing the negative behaviors day after day. The message to the mother is, “You have done such an incredible job being the mother of this boy. Look how much he has learned from you, how to behave in such a manner that other people find him likable and easy to be around. Let’s see if we can all work together to find a way for him to take this inner beauty home so you can enjoy it as well. You continue to love him even though he has done things to you that are very hurtful. I bet he secretly loves you very much as well and is afraid to let you know.”
The goals, then, of the child in TMR, are:
- Practice being respectful
- Practice being responsible
- Practice being fun to be around
- Practice doing whatever it was they failed to do or did when told not to
- To earn money for restitution for damages
What exactly, do these behaviors look like and why are they important?
One sign of respect is looking at someone when they are talking to you. Looking at someone is also foundational to the formation of any relationship. Failure to make eye contact is a sign of failure to connect. Anytime someone wants to initiate a relationship with someone else he or she first establishes that interest by looking at the other person. If that other person looks away then the person initiating the eye contact feels dismissed and unimportant. He or she might try several more times to engage someone’s attention by looking at them in hopes the other person will return their gaze but if, after repeated attempts to engage the other person visually, the other person continues to avoid eye contact then the first person tends to quit in discouragement.
Many children who were abused or neglected as infants or toddlers or who have had a series of caregivers never were given reciprocal eye contact by a significant other at a pivotal period of brain development. Their brains are, therefore, not wired to find reciprocal eye contact comforting or welcome. However, the wise parent knows the child must find ways to overcome this reluctance if he is to move forward in his life and find meaningful relationships out in the world beyond his family. People who do not engage in reciprocal eye contact with coworkers or acquaintances rarely can move those superficial relationships to deeper ones as other people will think of him as being “stuck-up” or “arrogant”. The world will not interpret an individual’s refusal to look at them as an indication of early childhood neglect. It will not have an empathetic response. Rather, the world will distance itself from those it finds distant, as is the case of those who refuse to look when someone is talking to them. Keeping the necessity of developing future relationships in mind, the message from the parents always contains a variety of these kinds of messages:
- “I am a powerful enough parent and have so much love for you that you don’t need to do anything different or be anyone different in order to be loved by me. However, if you want to be loved by anyone else in your life you might want to tweak a few behaviors so others learn to love you as much as I do.”
- “I can love a child that doesn’t look at me when I talk. No problem. However, the world establishes relationships by looking each other in the eye.”
- “You are fortunate that I am a powerful enough mom and a smart enough mom that I can teach you how to be loved by others. I love you too much to imagine you being lonely the rest of your life.”
The role of TMR is reinforcing this skill. It is often easier for a traumatized child to look into the eyes and face of a stranger or TMR provider as the face and eyes of a stranger do not carry the weight and fear of a loving relationship behind them. The fear arousal systems of the child are then momentarily disengaged while they practice the behavior and see that they can do it and not be hurt. Nothing bad happens to them because they are looking into someone’s eyes. What fires together wires together, so the rewiring in the brain that can take place during respite, when practiced sufficiently, can carry over to the parent-child relationship.
The same can be said of the development of a reciprocal smile. Smiling and eliciting a smile in response is critical to the development of future relationships and must be practiced in TMR if the child is refusing to practice it at home. It is disrespectful and somewhat frightening to many parents to find that their child avoids all contact with them while becoming quite affectionate with strangers. As with all disrespectful behaviors it is not the ego of the mom that is at stake. It is the ego of the child’s! To go through life believing and acting as if all relationships are equally important and he is not special to anyone is very damaging to a sense of self esteem. Part of the belief system of emotionally healthy people is knowing that they love and are loved by a group of family and friends that find them unique and special in all the world. They know they are not interchangeable with anyone else. This knowledge is a huge boost to one’s self esteem. On the other hand the belief that all people are interchangeable with all other people, no one is special, you don’t matter in any particular way to anyone and no one matters to you in any particular way is very destructive to a person’s, especially a child’s, sense of self. A family can go only so far in helping a child with an attachment disorder create a special connection to them. This particular skill is sometimes taught easier in its absence then its presence. A TMR provider can provide that environment where the child experiences their desire to be in an environment where no one particularly cares for him more then anyone else. This experience can sometimes be eye-opening for the child. When a child is given what he believes he wants…for example…no loving mother….. there is the opportunity for great thoughtfulness to occur. When a child is given the opportunity to try out something he thought he wanted……a life not connected to others…… he can then step back and look at it to see if he likes the way it works out for him. Whatever thoughtfulness he gained from the experience he can use in future choices. He can choose to act as if he is not special to anyone, particularly not special to his family, and they are not special to him or he can act in such a way that his behavior acknowledges that he is special to his family and he wants his family to know they are special to him as well.
The role of speech is also important. Speech that is unintelligible from a child that is capable of great clarity of speech is disrespectful and avoidant of relationship. (Not to be confused with shy children or those needing speech therapy) It is a means to control an adult by attempting to force the adult to engage in conversation on the child’s terms instead of the grownups. It is therefore important that the child practice speaking clearly so the TMR provider does not feel as if a “What?” response is required. A child who mumbles is exhausting to a mother as she must continually be finding ways to address it. Yes, the mother can ignore it, consequence it, paradox it, and use numerous other techniques to reinforce the concept that mumbling is not acceptable. However, all of those mean that the mother must be continually on her guard when ever her child speaks in order to appropriately respond. This is exhausting. There comes a time when the mother must simply say, “I need a break from constantly being on my guard.” It is therefore up to the TMR provider to give the child time to practice speaking clearly.
Quite the opposite of mumbling or speaking too softly for the parent to hear is the tendency of some children with attachment disorders to speak constantly or fill the air with an endless supply of noises, grunts, sighs and whistles. The child may be acting out a legitimate need to overcome and override the negative chatter in his head and interrupt the negative stream of traumatizing images. Nonetheless, the interminable mind-numbing chatter that can invade the family environment is intrusive and controlling. It is an attempt to force the family attention on the noise and the noise maker. Many mothers report this behavior as being one of the most exhausting to endure. Mothers of children with attachment disorder know that the child’s questions are a means of taking control, not a means to gain knowledge. The uninitiated outside of the family find the questions endearing and look fondly on the child with a look of intense interest that the child is so bright and eager to learn about such a wide variety of subjects. To the mother who has now been asked, “Why is the sky blue? Is this spaghetti?” for the tenth time and who knows the child didn’t listen to the answer the other times and has no intention of listening to the answer this time, her response is to fight impatience and look for meaningful ways to respond that will encourage appropriate and conversation in the future. The goal of the TMR provider can be to help a child practice good quietness. One response that both the mother and the TMR provider can give is to ask the child, who is chattering nonsensically, “What thought or feeling are you trying to forget about right now?” Another response they both can use is, “That is a very good question. Go write the question and the answer down.” It is important that children practice in TMR going inside of themselves and exploring their thoughts and feelings. Developing a habit of good quietness that they can take home and use at home and school to explore the same deeper thoughts and feelings is an important goal of TMR.
Refusing to eat the food mother lovingly prepares is another way children can demonstrate disrespect. Part of being a family is sharing meals and food together. One of the ways that many mothers show their love for their family and their willingness to nurture all of the family members is by preparing nutritious, delicious meals. Gathering around the table is indicative of the family bond. The time members of the family spend at the table sharing stories of their day, thoughts and feelings is important to creating family connections. The child with an attachment disorder can disrupt these feelings of good will by talking rudely about the food, by refusing to eat it, by engaging in obnoxious and disgusting eating habits, and by doing other things that divert attention away from the family bond. For some children with attachment disorder the closeness of the family bond exhibited at mealtimes arouses huge discord in them. Out of their discomfort they do everything in their power to create chaos and disorder in the family environment to reflect the chaos that is inside of them. Parents can address these behaviors in numerous ways, however, when the family is exhausted from continually needing to “address” these behaviors then it is helpful for the TMR provider to step in and give the child opportunities to practice finding a way to balance being the center of attention at the table and NOT being the center of attention at the table.
Being dirty is another example of disrespect. Not wanting to wash and be clean can have huge psychological underpinnings. An attachment disordered child may find that the feeling of clean skin is foreign due to the amount of time he spent being dirty and neglected in earlier childhood experiences. The brain wiring that makes clean skin and hair feel good never occurred. Instead, the feeling of clean skin may make him feel naked and exposed and so he avoids it. The brain wiring that makes the smell of soap and shampoo enjoyable may not have occurred. In its place is a wiring that says the smell of sweat and body odors is normal and comforting. A child may reject feeling clean as a means of continuing a survival mechanism that was much needed in earlier homes where he lived. He may have learned that being dirty was one way to keep from being attractive to a molester. With that understanding the mother and the TMR provider can work together to find ways to let the child know that while the behavior was good and useful in previous life situations, it is now disrespectful and counterproductive to happiness. The family can love the child within the confines of their own home but if he wants to go out in public with them and have fun times with them then he needs to not draw negative attention to himself and the family by being dirty. The defense mechanism of being dirty is no longer useful unless the child wants to grow up having people avoid him due to his body odor and greasy appearance. If that is not the case then it is time to find ways to practice being clean. This can certainly happen in the home. However, when the parent becomes exhausted with the struggle and does not want the appearance and smell of the attachment disordered child to sabotage fun times for them it is time for the TMR provider to step in and help out.
Children who grow up unable to take responsibility for numerous arenas of their life have difficulty living independently. It is important, therefore, that when a child is notoriously irresponsible to the point where his parents are exhausted by the 24 hour, 7 day a week supervision he requires that he go to TMR so the parents can recharge their batteries and spend time with those children who are behaving responsibly and deserve recognition for that.
One of the basic tasks of being in a family is taking on an age appropriate responsibility for doing what each can to enable the family to run smoothly. Chores are important for numerous reasons. They teach a child to be reciprocal. They demonstrate to the child the importance and difficulty of keeping a family environment safe and welcoming. They make it clear that the parents are not the child’s servants but that everyone must contribute to his own ability. They give the child an opportunity to practice doing a task the way someone else wants it done, not just the way he wants to do it. This is very important for developing a paid relationship with future employers. Every chore that is mastered gives the child a sense of competence and the knowledge that he is working toward adult independence and living on his own. Following directions and task completion are vital for success in school and in life.
For these reasons, and numerous others, it is important for a child to learn to be responsible for his body, his possessions, his schoolwork and his family chores. This teaches him to share the responsibility for a successful life. When parents tire of teaching this task they must hand it over for the time being to a TMR provider to continue the high level of structure and accountability required to keep the child in a “steel box with a velvet lining.”
Part of growing up to be able to live independently is developing the ability to be trusted. People who have to be watched all of the time to make sure they are doing the job they are supposed to be doing, to make sure they are not stealing, to make sure they are not breaking things, to make sure they are not sneaking around have difficulty holding jobs. Because a child with attachment disorder is often superficially charming he will have no trouble getting a job. The problem for him is keeping the job! In order for parents to teach the skill of trustworthiness to a child they must be able to watch the child very closely so the child does not get any benefit from sneaking around. The child must be again, “kept in a steel box with a velvet lining.” The child must know he cannot successfully sneak around so he begins to relax in the knowledge he is safe and everyone and everything around him is safe. Every time a child successfully sneaks around and/or steals he is proving that the adults are not smart enough to keep him safe and the world safe from him. This leads to a continual testing and hypervigilance to see whether or not this moment or that moment is more advantageous to sneak around. The child’s brain must tire of the exercise from the sheer futility of it. However, sneaking around and stealing are like gambling in the way they reinforce the brain, specifically the area of the claudate nucleus. Intermittent success is the most conclusive way to engrain a habit. Gamblers gamble because they are intermittently successful just often enough to reinforce the gambling. If they always lost they would quit. If they always won the casinos would have to shut down. They have to win just often enough to keep their interest piqued. Such is the way of attachment disordered children who wish to practice their “sneaking around” and stealing skills. The more the child is even intermittently successful the longer the behavior will continue. Maintaining this level of vigilance regarding a child often makes a normal home life impossible for the parents and the rest of the family. Thus, it is often best to allow a TMR provider to take up the task. The message to the child is, “At a critical period of your development the adults were not watching you closely enough. When you were not watched closely you were abused and neglected, you were not safe. It is perfectly understandable that now you need to make sure you are being watched every minute in order to convince you of your safety. We are glad to provide that for you. However, it is hard to do alone so we are going to periodically hire someone else to watch you. When you feel safe you will stop acting out in unsafe ways. We want you to totally know that you are always safe. Someone will always be watching you until you show us you are ready to take responsibility for watching yourself.”
Another mark of irresponsibility in a child might be the need to make sure the adults in his life are always at odds with each other. Triangulating adults is another “Watch me” behavior. For example, the child might duplicitously say, “At home I am allowed to have candles in my bedroom.” Or, “At respite I am allowed to play with the dog by myself.” These types of false statements put the unwary parent in the position of doubting the TMR provider and the TMR provider in the position of questioning the parents’ abilities to be trust worthy, appropriate parents for the child. It is also a means to take control and make sure the adults are aware that as a group they are not keeping him safe. It forces the adults to get on the same team and talk to each other. It allows the child to make sure that adults always know what he is doing so the transition from one setting to the next is safe. When adults drop this safety net for the child he feels unsafe and has to escalate his “watch me” behaviors until the adults take his need seriously and compare notes on how to make sure his care is consistent. TMR providers must vigorously report to the parents anything the child says or does that would superficially appear to have the effect of undermining their trust in each other. If the child is capable of playing adults for a group of fools then he is in control of the situation. If the child is in control of what the adults are saying, thinking and believing about each other and the way they interact with each other the child is not safe. Clear communication between all adults at all times is essential to minimize this issue.
When children are cruel to animals it is the height of irresponsibility. Children in TMR should have no pet privileges. They should not be allowed to pet the animals, feed the animals, walk the animals or be alone with the animals. Hurting an animal drives pathological behavior in deeper. Learning to care for and interact with pets is a skill taught only by the parents. Parents are generally the best judge when animals are safe around a child so the rest of the team must follow the parental lead unless they see that the parents need more help in the area of discerning the safety of pets.
Being Fun to Be Around
Many children with attachment disorders are not capable of taking good care of themselves so they are exceptionally poor at taking care of peer relationships. Leaving them alone with peers is rarely a good idea as they destroy not only the current relationship but also the future potential for relationship. Children can be very forgiving, but they also can remember that the last time they played with this particular little boy (or big boy or girl) he was bossy or hurtful in some way. They can carry that memory for a long time so it is best to keep the child away from other children so they don’t get a reputation for doing weird and cruel things. They will need those children as friends when they get well! TMR is an excellent time for a child to observe how other children behave. He is often so upset in his own home that he fails to take advantage of just sitting back and watching how other children in the home behave, with the hope of mimicking that behavior as a learning experience. He also has a tendency to believe that there is nothing wrong with him but a great deal wrong with his family. By being in a TMR home he can sit back, while he is not so edgy, and watch how other children behave. He can see that his siblings are not any different from other children in terms of their expectations of relationship.
Children who are whiny, fussy, and demanding are acting as if their needs are the only important needs to be met in the world. This is NOT fun to be around. It is exhausting to listen to someone harp and moan and bemoan. When parents have tired of consequencing, separating themselves from the child, separating the child from themselves, correcting, ignoring and paradoxing their child’s whiny and fussy behaviors it is time to take a break and let the TMR provider work with the child for awhile.
What It Takes to be An Effective Therapeutic Respite and TMR Provider
Central to being an effective therapeutic respite and TMR provider is belief and trust in the parents and their goodness, wisdom and strength! What the provider believes about the parents will determine the way they treat the parents and interact with the child. The provider must be able to understand and accept the parents’ perspective and appreciate the parents’ decisions. If the provider is more sympathetic with the child than with the parent that will come shining through during the therapeutic respite and triangulation will occur.
That is not to say that if a provider has questions about different things the parents are doing that they must not ever say anything for fear of being considered unsupportive. If a provider believes that the parents are engaging in parenting techniques that are inappropriate or unhelpful she must question the parents about it in such a way that the parents feel she is being helpful not conducting a personal inquisition. If the questions arise because of something the child has said or done that must be approached vastly differently then if the questions arise because it is something that the parents have shared they have said or done. In the first case the veracity of the child is so clearly in doubt that talking to the parents about it is more in the form of a report. In the second instance a response is required. If the provider sees inappropriate interactions between the parent and child that must not be ignored it must be approached with great sensitivity with the understanding that many times a parent does act inappropriately out of the depth of their frustration and fatigue. That is a time when the respite provider can lovingly offer to keep the child longer in order to give the mom a greater opportunity to recover.
At the same time the provider must not ever pathologize the child and see a mass of symptoms and bad behaviors instead of a very scared, angry child. There must be a healthy respect for the child, not for the child’s pathology. Sympathy is misguided. Empathy for the abuse and neglect the child suffered that brought his behaviors and emotionality to the state it is in the present is healthy. Empathy for the child must shine through in every word and interaction. No sarcasm. Anything said in sarcasm cuts off all thoughtfulness in the child and good therapeutic respite and TMR must arouse thoughtfulness in the child if the child is going to make decisions that are good for him and his future. A good approach is to mean business without being mean. Any discipline that is used must always be for the healthy development of the child’s ego, not for purposes of punishment or humiliation. Fear and shame are not therapeutic!
The provider must have a willingness to help in the way she is asked to help, not in the way she is used to helping or wants to help. She must definitely be past the need to help in a way that feels warm and fuzzy to her, regardless of how it hurts the child and family. Most foster parents have been trained to work with children whose abuse and neglect needs to be met with huge doses of nurturing. Enveloping a hurt child in loving arms is perfect and appropriate for those children whose abuse and neglect have left them hungry for attention and love. However, a parent who wants to provide therapeutic respite and TMR needs to understand that some children take that abuse and neglect and become abusive! It is those children and their families she is called to help! She must be guided by the directions of the parents and accept that they know best what is good for their child. She must accept that the child has a family that is loving, nurturing and caring and the child is rejecting it. If she steps in and tries to replace the parents out of misguided sympathy she will undermine the child’s ability to form a relationship with the only people who have made a long-term commitment to his care – his parents. She is not there to be the child’s buddy or pal. She is there to be the buddy and pal of the parents! The goal of the provider is to point the child to the parents and make the parent look good, not replace the parents or wiggle into the child’s affection by placing herself between the child and his parents. Therefore bonding activities such as hugs, kisses, loving eye contact, affectionate touch, sugary treats, chatty conversation, endearing smiles, etc must be avoided. These must come from the parents! The therapeutic respite and TMR home must be differentiated primarily by their absence. If the child wants the loving interactions of a parent then the child needs to get himself home to his parents! Whatever bonding overtures the child receives from the provider can be used by the child to keep pushing his parents away. When the provider eliminates the thoughtful, little loving gestures a mom gives a child in her interactions with the child the point is not to create suffering, but to cause thoughtfulness. The provider must not lose track of what the child was doing in the home and with his mother to push her away and make himself difficult to live with. Just because the provider doesn’t see the behaviors does not negate their presence. Besides, many of the loving interactions and activities a provider wants to do with the child are ones the mother wants to do as well…..but the child’s behavior is so impossible to manage she can’t!
Time is essential to be an effective provider. Most of the time families can’t plan a time when they will need respite. The child misbehaves or makes it clear somehow that it is no longer appropriate for the child to be included in the family activities and the provider needs to be available to step in and take over. Setting aside the time to be on call in this way means that respite care is expensive. At this time it can cost between $50 and $200 a day. It costs that much, not because the respite provider needs that much per day per child, but because she needs to be paid sufficiently to carry her through the days she is not needed. Families need to pay not only for her services but her availability and liability!
A good therapeutic respite and TMR provider must attend trainings, read books and view DVD’s to be continually upgrading her skills. She must know to the depth of her being that a child who is used to being abused can work to recreate that situation again and again and must be on her guard to avoid being trapped in it. Many children with histories of abuse and neglect have used and manipulated that history to bring out the worst in adults and caregivers. It is these understandings, skills and experiences that will make her an essential help to the family. At the same time she must be willing to make mistakes. That is how people learn. The children are patient teachers and will continue to engage in a behavior over and over again until the entire team figures out how to appropriately respond. An inability to figure that out the first time is not a mark of failure, it is a mark of determination and patience. Being patient with oneself is just as important as being patient with the child. Handling personal mistakes well models for the child how to do the same. Demonstrating that she is able to forgive herself is excellent for children to observe who believe they are intrinsically bad.
A difficult skill that the provider must hone to a sharp edge is the ability to be continually vigilant! Many children have developed the ability to grope another child when passing from one room to another, when they are out of sight of an adult for no longer then 2 seconds. When a child is in therapeutic respite and TMR the provider must be exceptionally vigilant to see that nothing is stolen or broken from the common areas of the home. She must also inspect chores carefully to see they are complete and done correctly. Her attention must be so excruciating for the child to endure that he gets the message loud and clear that he never wants to return and be subject to such scrutiny again. Attention to detail also means correctly and consistently administering prescribed medications at the right time and in the right dosage.
An important discipline for the entire family of the provider is to make television watching and computer activities either side events or not events at all. The child in therapeutic respite must not watch any TV, use the computer, play Nintendo or engage in other electronic games. These activities wire the brain of the child in the opposite of what is needed to be a productive, cooperative member of a family. A child in therapeutic respite and TMR cannot practice the skills necessary to go home if he must always be in his room while the television is on in a central location. Therefore the television, if the family has one, needs to be in a side room where only family members congregate.
Naturally a child in therapeutic respite and TMR must have a separate bedroom with its own alarm on the door. The message must be clearly delivered to the child that not only is he safe at night, but everyone else in the home is safe as well.
Lastly, a therapeutic respite provider must have chores available! The basic reason why most children would need to go to therapeutic respite and TMR is because they are taking more from the family and parents then they are giving. One way to change that balance is by learning to do things that fill the family up and contribute to the overall functioning of the family, instead of always draining the family dry. Whenever the balance in a relationship shifts from more ‘good times then bad times’ to ‘more bad times then good times’ the relationship is jeopardized. A rule of thumb is that there needs to be five positive interactions for every one negative interaction if a relationship is to survive. Chores teach reciprocity, very practical ways to give back to others. They also clearly demonstrate the parents are not the child’s servants. When the child is so excruciatingly difficult to manage that the parents begin to question the point of having the child in the home, the placement is in trouble. Avoiding that burn out point is one of the goals of therapeutic respite and TMR. Teaching a child ways to give back by folding the laundry, mopping the floor, raking leaves, wiping down the cupboard doors……anything he can do at his cognitive, emotional and physical level is critical to teaching a child ways to maintain himself in his home. The likelihood of a child being able to demonstrate efficiency on a chore is higher in therapeutic respite and TMR then it is in the child’s home as the child does not get an emotional charge from the provider taking charge in the same way that the child gets overwrought at the possibility that his mother, who he has not learned to trust, is actually going to be in control of him in some way. Once the child is able to demonstrate competency on a task in the respite home it is generally, but not always, easier to transfer that competency to his own home with his own mother.
Additionally chores teach life skills and build competency. Anytime a child feels more competent his self image goes up as he sees himself as a worthwhile, capable human being. Doing chores gives a child the means to earn money to provide restitution for broken items, torn clothes, holes in the wall and other destructive activities the child has engaged in.
Competency on a task means the child is doing it quickly and right the first time. Extraordinary delaying tactics and leaving part of the task undone are classic ways that a child can demonstrate that he will look like he is doing the chore, but he really isn’t. He will do the chore this far and no further. It is a very passive, yet aggressive stance on the part of the child and parents know it. When a child approaches tasks this way the parent knows it is easier to do the chore herself then to get the child to do it. Breaking this cycle is one reason why a child would go to therapeutic respite. The provider has no way to force the child to do things quickly and right the first time and has no desire to do so either. Therapeutic respite is about providing the child numerous opportunities to make good choices and to practice skills that enable them to live at home. It is not forcing compliance. It is not about control battles, winning control battles or being boss. It is about presenting the child with opportunities to develop the skills necessary to avoid exhausting his parents to the point where they need him to be gone for awhile so they can regroup. The provider must go along with whatever decision the child makes and help the child see how that decision works out for him. The provider needs to give the child permission to do what he is going to do anyway, while letting him know in gentle, yet firm phrases, that doing so will mean it will take him longer to get home. And…..that is OK! He can take his time!!!!!
Typically a child in foster or adoptive placement had no choice in whether or not he was going to be placed in this particular home with these particular parents. Therapeutic respite and TMR gives the child the opportunity to miss the loving things about the family that he was fighting against and choose the family and parents that chose him! Or not. The goal of the provider is not to force a child to go home when he clearly doesn’t want to. Rather, the goal is to help him decide whether or not his home is a good place for him to be and then help him find the means to get himself back.
Accomplishing all of this requires that the respite provider be respectful of the child, while holding the child accountable. “Mean business without being mean” is the operative phrase! The home must be safe, yet emotionally distant in order to avoid competing with the parents for the child’s good will. One way to avoid competing with the parents for the child’s good will is to create a standard of task completion that is higher then what the parents would expect. The provider must establish a very high degree of excellence so the parents can ease up and appear magnanimous. That way when the child goes home he is relieved that his parents are so generous and undemanding, instead of believing that the provider is more generous and undemanding then his parents. The provider needs to make the parents look good, not bad. The provider needs to create an atmosphere that is safe, professional and business like, so the child feels better, more loved and cared for, when he is around his parents, not better when he is around the provider. The provider, in short, creates an environment and system of interaction that helps the child become thoughtful about what he is missing in his own home and desirous to return, not grateful that he is not at home.
The greatest compliment a provider can receive is from the child, when he says as he walks out the door, “Mom, I am so glad to see you. I sure don’t want to come here again!” Reaching for mom while distancing himself from the respite mom is a worthy accomplishment.
Overview of Philosophy and Goals of Therapeutic Respite and TMR Providers
- Trust Parents
- Listen primarily to parents
- Be guided by parents and therapist as to what constitutes appropriate respite for the child at this time
- Communicate with parents
- Check out FIRST with parents what child says
- Avoid triangulation and manipulation
- Mean business without being mean
- Provide safe, business like environment
- No bonding activities
- Avoid competing with parents for child’s good will
Goals of Therapeutic Respite and TMR for Child
- Chores done efficiently and right the first time
- High level of task completion
- Go to room quietly and quickly the first time asked
- Stay in room until given permission to come out
- Develop good self control skills
- Develop respect
- Develop healthy communication skills, especially listening
- Develop responsibility
- Develop ability to be enjoyable to be around
- Develop appropriate expression of feelings
- Develop the ability to accomplish whatever task the child refused to do that exhausted the parents and caused him to need respite
The Structure of Respite
The key word is structure! Therapeutic respite is highly structured for three reasons. One, it increases a child’s sense of safety when events are under the control of parents. Two, the high degree of structure makes home look more appealing. Three, much has to occur in respite in order to get the child moved back home quickly and the more structured the opportunity the more quickly the child can accomplish the goal. The steady influence of tight structure encourages the brain to rewire itself around the necessary skills.
The structure begins when mom and the child walk in the door. The provider greets MOM first. She talks to MOM first. Only after she has effusively greeted mom does she turn to the child and in a business like voice direct him where to put his bag and where to strong sit. If the child does not yet have this skill then the provider just tells him to sit on the floor facing the couch until the two adults are finished talking. The provider and the mom go over the Respite Brochure (see Addendum). Hopefully the mom will have it filled out prior to arriving. It contains the child’s name and birth date, information on medication management, allergies and special medical conditions the child has, whether or not the child has problems managing his bodily wastes, emergency contact information, outlines what tasks the child needs to be working on and what conditions are for the child to return home. For example the child needs practice going to his room and mom will pick him up when he is predictably going to his room when told. Or, the child needs practice with not continually drawing attention to himself and he will be picked up on Friday at 4 whether or not he has accomplished that task. It is always up to the parents to decide when to pick the child up from respite. Sometimes it is dependent on the accomplishment of a task. Another time it might be when an absent parent returns and so both parents will be available to monitor the child. Another time it might be dependent on mom calling in and saying she is now rested sufficiently to jump back in. Whether the time is open or task dependent is up to the parents and needs to be decided prior to dropping off the child. The time when the child is going to be picked up or the conditions that must occur before the child is to be picked up is not information that is shared with the child. This is important as it helps prevent the child deciding that he will simply wait the process out and not participate in the learning opportunities.
There are numerous statements the provider can sprinkle into her conversation with the mom during this time. “I sure am glad you are taking a break. It must be hard to always be working so hard to help your son.” “We all get tired.” “You are such an awesome mom. He is so lucky to be loved by you.” “You have a great time, go out to a movie, have fun with the other kids. You all deserve some fun times. He will be fine.” The point is speak the truth in a light hearted way and uphold the parent both in her eyes and in her son’s eyes, demonstrating that not everyone has the same low opinion of her that he does. Avoid any criticism. Leave that to the therapist. Most parents are well aware of the mistakes they are making and are already guilt ridden over them. They do not need to have them continually pointed out by others. Rather, the role of the provider is to praise the parents for being able to keep their commitment and continue to love their child…….and what a priceless commitment that is!
At this point the child could go through histrionics of missing his mom. This is generally a tactic to control mom further by delaying her leaving and make her feel guilty. Mom and the entire family have been controlled by the child to the point of exhaustion so she does not need to be controlled one more minute. Additionally, there is absolutely nothing for mom to feel guilty about. She has brought the child into their family home and he has done little except push the family and mom away. She needs a break so she can return for her child with love in her eyes. The provider can say to the child, always gently and kindly, yet speaking the emotional truth, “If you wanted to be with your mother so much you could have done more at home to show her that.”
After mom leaves the provider goes through the child’s bag to make sure there is nothing in it that the child should not have, such as snacks, drugs, weapons, electronic toys, matches, etc. This is not an invasion of privacy. Rather it reinforces for all that the safety of the child and family will be of high importance. It is also good for the provider to make either mental or written notes about the contents of the bag in case something turns up missing and the child claims, when it is found in his bag, he brought it from home. The child is then given his sheets and blankets and taken to his room, a room he will not be sharing with another child. He is given the task of making the bed if he is older then five years old. His bag stays with the provider who will give him clean clothes and hygiene items as they are needed. During this respite time the provider will be teaching or reinforcing the discipline of saying “Yes, Mom Cheryl” whenever he is given a directive. Learning opportunities in various forms follows. The more adept and cooperative the child is at saying “yes, mom ____ (name of provider)”, strong sitting, jumping jacks, chores, mealtimes, going to his room when told, coming when called, etc, the more free time he can earn to play quietly within a designated boundary. The provider does not say, “Please” or “I need you to”. The provider simply states the request, “Come here” or “I want you to make your bed.” So, it is not “Please come here,” or “I need you to make your bed.” The purpose is to make it clear that these are not negotiable requests but a very clear and firm expectation. Whenever the child is spoken to the child is expected to respond. This is polite and respectful.
The rules are clearly stated. The older then five child must ask permission for everything. If the child wants to go to the bathroom he must ask. How he asks is taught. If he is standing he is to come near to the provider without crowding her, look at her expectantly and then wait for recognition from her that he can speak. This is polite and is what all members of society do at all levels. It is impolite to stand too close to someone. It is impolite to hold one’s crotch and jump up and down. It is impolite to interrupt others. These basic human niceties bear being reinforced in therapeutic respite. If he is sitting he can say, “Excuse me, Mom _______.” The provider will acknowledge him when she is ready. All verbal interactions must be spoken appropriately. No whining, complaining or arguing.
Another rule is that he will eat what he is given…..or not. However, unless a special diet has been prescribed, creating food hassles for the provider is not an option. If he is behaving cooperatively he can eat with the family. If he is not, he needs to eat separately. If he eats appropriately and politely he can remain with the family at the table. If not then he needs to eat either at a different time or in a different place. The food provided must be nutritious, well prepared and sufficient. Dessert is not served to the child in therapeutic respite or TMR. It may, however, be set aside for his mother to feed him when she returns as part of their bonding activities.
There might be times when the child is served what is known as “soup kitchen” meals. These would be meals consisting of sandwiches, soup or anything else the provider can prepare without the investment of a great deal of time, energy and nurturing. If the child has been served perfectly adequate and fine meals at home and is refusing to eat the food lovingly prepared by his mother for him it is not good for him to go somewhere else and gobble up someone else’s nurturing. Hopefully the child might say internally, “I don’t miss my mom, but I sure miss her cooking.” Anything the provider can do to create appreciation for mom in the child’s mind can be considered as being potentially beneficial….such as, not cutting the sandwich. Loving moms always cut their child’s sandwich in order to make it easier to eat. It is a small but notable absent gesture for the child to experience.
Little time in therapeutic respite and TMR will be spent playing. More time will be devoted to the development of self control. Anytime the child does what he is asked to do when he is asked to do it, he is practicing good self control. Eye contact, saying “Yes, Mom ______” when spoken to, clear speech, are all skills to be reinforced over and over again as the brain needs to be rewired around them and repetition will make them more automatic with his parents when he goes home. For example, if the child’s morning routine at home has typically been to go so slowly that everyone is late all of the time a good task in respite would be to practice the morning routine of getting up, getting dressed, eating, brushing teeth, putting on shoes and standing by the door until it is automatic for the child. The child can be sent to his bedroom every hour and told to put on his pajamas. As soon as his pajamas are on the provider comes and “wakes” him up and the morning routine practice begins. This is done over and over until he consistently does it right. It doesn’t have to be done over and over again all day long, however, numerous opportunities must be provided to practice. This does not have to be onerous. It can be cast as a fun, timed event with lots of pizzazz from the provider each time a second or minute is shaved off the time.
Chores are assigned depending on the ability of the child. Depending on the age of the child it is appropriate to expect a child to do 30 minutes to one hour of chores a day. The time is not based on how long it actually takes the child to do the chore, but rather on how long it should take the child to do it. The child can take as long as he wants. They must be done quickly and completely in order to be counted toward progression home. Doing chores is also an opportunity for the child to earn money to pay his family back for damages or to build up a damage deposit. It is also a way for children to earn the money to pay their parents for the time spent taxiing them around to respite. The child can earn his way back home. Typically the amount would be calculated on minimum wage times the amount of time it should take the child to do it. If the child wants to take more time, that is not part of the calculation of wages due. As soon as the chore is done the child must strong sit facing it for one minute to look the job over and see that it is ready. The provider then comes and checks it. If it is done correctly she can give him some praise and either set him to another task or give him play time. If it is not done correctly she goes to plan B, which is all of the interventions a parent and provider have at her disposal whenever a child does not do as told.
Time can also be spent exercising. This gets oxygen to the brain and enables it to think more clearly. Mini-tramps, jumping jacks, laps around the house, etc are all good forms of exercise. Writing in a journal is an excellent way to provoke thought in the child. The child could be asked to write any number of things in a “clean slate journal” as appropriate. Some examples:
- 10 lies I told my mom
- 5 things I have stolen from my family
- 3 reasons why I am in respite
- What I do to get other people to not like my mom
- How I hurt my brothers and sisters
- What I have to do to go home
- 10 things I have broken around the house
- Ways I try to push my mom’s love away
- Ways my mom is an awesome mom
Another appropriate subject for journaling would be:
The child could also write and/or illustrate letters of apology to:
- What did I do?
- How was I feeling?
- How did I handle it?
- How did it work out for me?
- How am I going to handle it in the future?
- People he has lied to about his parents
- People he has lied about
- People he has hurt
- People whose things he has broken
After a child has kept working on these various projects and has demonstrated a willingness to be thoughtful and cooperative, structured play time can be assigned. Typically the child would be placed on a blanket with some wiggle room, but not too much. A small child’s blanket might be three feet by three feet. A larger child would have a larger blanket. A toy would be given to him that the PROVIDER chooses and that he can play with by himself. The child should not be playing with other children or engaging with others in a fun way until after he is connected to his mother. It could be a puzzle, legos, Lincoln logs, book, latch hook or other activities that require fine motor control and concentration. Both the child and the toy must stay on the blanket. This teaching of boundaries and reinforcement of the skill of staying where he is expected to stay is critical for a child’s home and family to be safe with him in it. When he is done he sits quietly until the provider offers another toy or activity. The provider must make sure that whatever activity the child participates in or toy he plays with must be consistent with what the child is allowed in his own home. A child should never be given a privilege in respite that he has not earned at home!
The same rule applies in therapeutic respite as it does in the family. Never ask a child to do something if you do not know what you will do if he doesn’t. The provider must make sure she is well versed in paradoxical techniques in order to allow the child the freedom to make mistakes while finding ways to make sure the consequence of those mistakes helps the child become thoughtful.
Each day while a child is in therapeutic respite he can be given an opportunity to take a bath. Many experienced providers explain to the child when he first comes what the rules are for asking for a bath. It might be that as soon as he gets up in the morning he can ask for a bath. If he doesn’t ask then he doesn’t get to ask again until the next day. The rule can be whatever is convenient for the provider and thought provoking for the child.
Typically the child’s day would be to wake up and stay quietly in his room until the provider comes and turns off the alarm and invites him out. He needs to use the time between when he wakes up and when he is invited out of the room to make his bed. If he has soiled his bedding then it needs to be removed and placed in a neat pile near the bed. As soon as he hears the provider turn the alarm off he should be in his sitting position, facing the door or the side of the bed so that when the door is open the provider’s first sight is of him demonstrating willingness, thoughtfulness and self control. She can then either give him his clean clothes for the day if he has asked to take a shower or give him the same clothes he had on the day before if he is dirty and has not asked to bathe. If he appropriately asks to take a bath then he is taken to the bathroom, given shampoo, soap, towel and clean clothes and is given 15 minutes to clean himself and get dressed. When done he does not wander freely around the house. rather he waits in the bathroom for the provider, who has timed the 15 minutes
The day progresses with numerous opportunities to eat appropriately and practice various forms of self control, whether it is chores, saying “Yes, Mom _______,” speaking clearly, using good eye contact, jumping jacks, strong sitting, staying within his boundary, going to the room, etc. Basic rules would include no warnings and no second chances as then the child begins to lean on the adult to supply the inner voice he needs to be strengthening. In the evening the child is fed, sent to his bedroom early with a good book and the alarm turned on. His early bedtime is so the family of the provider can take good care of itself. Then they can have dessert, watch a movie, etc If he yells, bangs or is otherwise intrusive then that needs to be ignored until the next day when he can do extra chores to make up for it. If he needs to use the bathroom and failed to use it prior to going to his room then he is allowed to do so with the understanding that there will be a consequence for that choice the next day. If this becomes a disruptive, intrusive part of the child’s behavior then the response on the part of the provider can escalate to placing a potty chair or chamber pot in the room for the child to use. If he repeatedly comes out of his room in the middle of the night, setting off the alarm, wandering around the home, compromising the family safety and preventing the family from getting adequate rest, then a psychiatrist needs to be consulted and a request for a prescription for a temporary lock on the door can be obtained. Locking the door is an absolutely last option and there must always be an adult present to unlock the door in the event of an emergency. The message is that he cannot go home as long as he is engaging in such out of control behaviors that make it difficult for his family to be around him.
The appropriate time for bonding activities is when the mom returns. A sweet can be given from the hand of the mom to the mouth of the child, making sure the child does not take it out of his mom’s hand and feed himself. That is not bonding! Mom could feed the child ice cream or candy, something to reinforce the concept that mom is the source of goodness and love. When a mom slips a caramel into her child’s mouth the chewiness keeps him quiet and simulates the same sucking and jaw motion of a nursing infant. If the child is young enough or small enough time can be spent rocking the child with soft music in the background. The focus must be on the re-connection of the mother and child….not on going over all of the things the child did right or wrong or in respite. Talking must be from the mom to the child and the words must be filled with love and acceptance. Talking must not be between the parent and provider. That can be done on the phone before the mom arrives. While mom is reconnecting with her child the provider can go through the child’s bag and coat pockets to make sure none of her household items are hidden!
Sources for Therapeutic Respite and TMR Providers
There are many people who know and appreciate the value of tight structure. Military personnel, police officers and teachers are accustomed to imposing and maintaining the common boundaries required by our society. They are used to making sure group rules are applied to all participants. Teachers particularly tend to have the experiences and skills necessary to impose discipline in a firm, clear and kind manner.
Colleges and universities with psychology programs can be contacted for students who want to work with the population they are studying. For some of the students their youth might work against them, however, they tend to be quick learners and eager to help.
Classroom aides who work one on one or in small groups in the school with emotionally and behaviorally problematic children may also have the skills, experience and ability to be effective therapeutic respite providers.
Lastly, of course, are other parents with children with similar diagnoses, emotional states and behaviors. They are often the best resource as then no money has to change hands. The parents can form a respite cooperative and trade respite for each other. A side benefit of this arrangement is that often the child in the home who presents problems to the family makes radical changes in his behavior whenever the respite child arrives. He tends to want to show the respite child how good behavior looks and to demonstrate that he is not the worst kid. There is a “new worst kid” in the house.
Grandparents do not tend to make good respite providers as they are too emotionally involved in their grand child’s life to be able to maintain the emotional distance required. It also interferes with their vital role as grandparents.
Goals of the Parents
- Don’t worry
- Do not continually discuss the child
- Do something that’s fun
- Use time away to build up relationships that have suffered from the child’s presence
- LAUGH LOTS
Recovery and Healing
The goal of respite is for the child to return home!!!!! And STAY home!!!!!
Respite must be seen as an interim solution to a long term problem. It must not become a habit and used as a way to avoid the deeper family, parent and child issues that make it difficult for the child to be maintained in his own home. When a child must go to respite and therapeutic respite it is an indication that either the family needs more support, the parent needs more skills or the child needs more and more effective interventions.
Respite is an indication that the abuse and neglect the child has suffered in the past is still being resurrected and played out in destructive and painful ways in his present. If these issues are not resolved he is going to play them out in his future. The emotional states and behavioral issues that drive the family to frustration and exhaustion do not make the child happy. They are by-products of deep and abiding pain. They must be seen as non verbal cries of the child for help. No one, not the therapist, not the psychiatrist, not the parents, not the family support system and not the provider should see respite as the solution. It is only a temporary intervention that must necessarily be used in order to keep the family from disintegrating and the child’s placement from disrupting. If a way can be found to maintain the placement the love, nurturing and commitment of the parents will ultimately heal the child.
Respite is merely a stop gap until long term solutions are achieved. The long term solution may require more effective therapy, more effective medication, and/ or other more effective interventions. Services must be made available to both the child and the family so respite is no longer needed.
Leave no stone unturned until the family is able to remain a single unit for an extended period of time.
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