Helping Children Exposed to Substance Abuse, Mental Illness, and Violence
Each site participating in the Child Subset Study includes the
- A uniform clinical assessment for both mother
- 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
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
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.)
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
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
"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
"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.
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