Helping Children Exposed to Substance Abuse, Mental Illness, and Violence (Part 2)

Program Components

Each site participating in the Child Subset Study includes the following elements:

• A uniform clinical assessment for both mother and child

• Ongoing case management, including service coordination and advocacy

• A skills-building group intervention for the children that helps them to establish boundaries, improve their self-care and sense of identity, and develop a personal safety plan.

Susan O'Donnell, M.A., who serves SSTAR as both child clinician advocate for the WELL Child project and integrated care facilitator for the WELL women's study, stressed the importance of the second component, which includes "resource coordination and advocacy and/or case management, getting the kids services, and coordinating the services." Services can include psychotherapy, various kinds of after-school programs, and more.

Though the study's design permits only one child per family to enroll, Ms. O'Donnell said, "If there are other children in the family, I'll try and find services for them as well." In her role as clinician advocate, she said, "I help the parent as much as possible" obtain the services that both study children and their siblings need. As integrated care facilitator, she added, "I also case manage for the woman [and] the whole family."

Helping the parents throughout the process is a consumer coordinator who works in both the WELL and the WELL Child projects, Dr. Finkelstein said. In addition, the consumer coordinator recruits other women who've participated in the WELL program "who are further along [in their own recovery and] who have volunteered to be consumer advisors or consumer assistants to other women who might have questions," Dr. Finkelstein explained.

"It's one thing [for the mothers] to talk to me, a professional, but it's another to know that they can talk to another consumer" of treatment services, Ms. Gould added.

The program's third component—the skills-building groups—is based on a curriculum modified from Groupwork with Children of Battered Women: A Practitioner's Manual, by Einat Peled and Diane Davis. Because the Peled-Davis program focuses only on domestic violence, "it excluded some of [the] pieces" needed by children whose "moms have the three issues: mental health, substance abuse, and trauma," Ms. O'Donnell said.

Before the groups begin, parents receive a detailed orientation, learning what they might expect from group participation, including both positive and negative side effects. For example, Ms. Gould said, "the child might come home and start talking about how it's not okay or it wasn't okay when I saw this or that," a change the mother may find "uncomfortable."

Ms. Gould explained, "We learned from Peled and Davis that success depends on parents understanding that their kids are going to be introduced to [ideas and information] that no one may have ever taken the time to process [with them] at length." Children might, for example, "feel empowered to maybe challenge" their parents. Or the mother might experience reactions "triggered by the kids."

Designed for two age groups, 5- to 7-year-olds or 8- to 10-year-olds, each group meets for 1 hour and 15 minutes for 10 consecutive weeks, with "booster" sessions 1 and 2 months after the regular program ends. (See The Skills-Building Intervention.)

"Ways that hands can help," and "ways that hands can hurt," as illustrated by Jennifer during her participation in the skills-building group intervention of the Children's Subset Study.

To ensure sufficient group size and the opportunity for broader participation, the groups are generally open to all children age 5 to 10 of women receiving treatment at the sites, whether or not they are formally enrolled in the Children's Subset Study. For example, Jennifer's sister, Courtney, belonged to a group for 5- to 7-year-olds while Jennifer attended with the children age 8 to 10.

The sessions tackle complex issues such as a parent's substance abuse, exposure to violence, appropriate touch, expression of anger, and the right to be safe.

Each tightly structured session begins with a check-in that allows the children to discuss feelings about the previous session or other issues in their lives. In addition, each session takes a particular feeling—such as anger or sadness—as a theme for the day. The aim is to legitimize feelings the children experience and help them understand appropriate ways to express them. Or, as Ms. O'Donnell, who serves as a facilitator at SSTAR, put it, to help the child "connect . . . feelings, to get a vocabulary of feelings."

The children learn, for example, that "It's okay to be angry and express anger, but it's not okay to abuse others with my anger," she explained.

Specified activities make each session's lessons concrete. For example, the children discuss violence in terms of "what hands can do." Children trace outlines of their own hands. The younger children trace onto a group poster; the older ones onto individual posters. Then they suggest "ways that hands can help, [and] ways that hands can hurt," which are written around the fingers, Ms. O'Donnell said.

A snack and a ritualized closing add to the comfort of each session. Everyone forms a circle, holds hands, and "pass[es] the squeeze."

The curriculum's "strength-based model" allows the project "to build on the kids' strengths," Dr. Finkelstein said. As the weeks pass, they learn that they have the right to be safe, to assert themselves, and to protect the privacy of their bodies. The children devise concrete strategies for dealing with unsafe situations, and create "safety plans" that include safe people and places and how to reach them in case of need.

"Repeatedly what I hear [from parents] is, 'I wish I would have known about this when I was their age,' " Ms. O'Donnell said.

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How Children Respond

The groups become extremely important to their young members. "Every child we've had in the groups—except for one—we have kept throughout all the group sessions," Dr. Finkelstein said.

For example, Ms. Gould recalled, when one mother told staffers that medical appointments and transportation problems would keep her daughter away for 2 weeks, "the little girl, just impromptu, said, 'You don't understand mommy, this is very important work going on here and I can't miss the group.' "

Ending the program is "extremely hard" for the children, Ms. O'Donnell said. So, the project added monthly "reunion groups."

"I've been in the child psychiatry field for 20 years, and the attitude has been that you can't talk directly to kids [this young] around these kinds of serious issues," Ms. Gould said. But the Children's Subset Study shows that "with the right resources you can really talk with these kids on their developmental level and they get it. . . . If anybody would have told me we would be talking with 5-year-olds about such supposedly adult topics, it would have seemed impossible."

More results will emerge as the study continues. A common interview protocol and intervention will allow data to be pooled, analyzed, and reported across sites.

« See Part 1: Helping Children Exposed to Substance Abuse, Mental Illness, and Violence

See Also—Related Content—The Skills-Building Intervention »

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