Behavioral Versus Trauma-Informed Approaches in Children?
Avoiding false choices for complex minds
Posted Nov 15, 2019
Let’s say there is a 9-year-old boy who is being treated at a residential facility due to his dysregulated and aggressive behavior. Like so many children in these places, he has a history of abuse and neglect since he was very young. He also is, well, a kid – who has wants, interests, and motivations like any other child. Now let’s say he is spending a little downtime with a favorite video game when staff tell him his time is about up. He screams in protest, refuses to stop playing and, when confronted, goes into full meltdown mode, screaming profanities and throwing objects around the room.
What is the best next step staff should take? The options, once he and others are out of direct danger, might include the following.
1) Inform him that continued behavior like this is going to result in a loss of privileges, including not being able to play video games. Encourage him to take some space in his room alone with the provision that staff is willing to interact with him when he’s ready to engage positively with others.
2) Get down to his level and help him regulate by working together on various coping strategies while offering support and comfort. Do not link this outburst to a reduction in his preferred activities.
The first approach might be part of what is considered a more classic behavioral approach. This perspective often considers maladaptive behavior to be goal-driven (the child has learned that meltdowns give him extra video game time) or attention-seeking and thus use incentives and consequences to shape more positive responses. The key parameter that is being targeted with these kinds of interventions is motivation.
The second approach takes a different tack by asserting that motivation is not really the problem here and that these kids are already motivated to do well but can’t because their early experience and trauma have wired their nervous system in a way that makes it extremely difficult keep their emotions in check and deal with frustration. To help, what is needed isn’t more motivational enhancements but environments that help children feel safe and supportive adults who can teach and model regulatory skills in a more flexible, less punitive manner.
Lately, there has been a decided shift across many psychiatric hospitals, residential facilities, therapeutic schools, and even when giving parental advice to move away from behavioral approaches and towards a more trauma-informed perspective. Indeed, some behaviorally oriented techniques such as time-outs have been phased out and reclassified as forms of seclusion to be avoided except as a last resort.
While a shift in this direction has been long overdue in the minds of many, there is also emerging concern that the pendulum may be swinging too far in the other direction. A recent study in the Journal of the American Academy of Child and Adolescent Psychiatry tracked the consequences of a phasing out of their behavioral approach on an inpatient psychiatry unit for children, most of whom were admitted due to aggression and extreme dysregulated behavior. What they found was that as the unit shifted out of its behavioral model, the number of kids needing urgent psychiatric medications or more extreme interventions, like a physical restraint for their own or others' safety, actually went up. However, a valid critique of the study is that the absence of a behavioral model is not the same as the presence of a full-fledged trauma-informed one.
When cornered, most mental health professionals will acknowledge that the behavioral versus trauma-informed debate is a false dichotomy, with both approaches having value. This recognition, however, doesn’t prevent the squabbling and critiques that advocates on either side can air. Neither does it eliminate the choice someone has to make in moments such as described above.
Moving forward, the trick may be in not giving in to extreme and rigid policies on either end of the behavioral/trauma-informed spectrum and instead allowing for a degree of flexibility to address different kids in different moments.
Institutions may do well to mirror the approach of astute parents who recognize that, even within the same individual, there are times when a behavioral outburst is under a child’s control and instances when no amount of incentives or consequences are going to bring a child back to baseline. Knowing where that line exists is much clearer when one can be confident that the environment is working in a way that is encouraging kids to do their best. Just because a child has suffered adversity or trauma doesn’t mean that he or she has lost the ability to make some modifications in behavior according to what, at least subjectively, “works” for them.
What this all may mean in practice is the need for adults to make a well-informed (albeit difficult) judgement about which type of response is warranted in the moment, followed by an honest evaluation of whether the approach worked. If it didn’t, you consider something else. This sounds simple, but it’s amazing how often dogmatic thinking can get entrenched into policy even with something as variable and complex as human behavior.
Carlson GA, Chua J, et al. Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study. J Am Acad Child Adolsc Psychiatry 2019; epub ahead of print.