Children and Youth Who Demonstrate Aggressive Behavior at Church…What to Do?

1. Children and Youth Who Demonstrate Aggressive Behavior at Church…What to Do? Stephen Grcevich, MD President, Key Ministry Assistant Professor of Psychiatry, Northeast Ohio Medical University Senior Clinical Instructor, Child and Adolescent Psychiatry Case Western Reserve University School of Medicine 2011 Bioethics Conference and Through The Roof Summit Cedarville University September 17, 2011 Key Ministry, 8401 Chagrin Road, Suite 14B, Chagrin Falls, OH 44023 Phone: (440) 543-3400, E-mail: steve@keyministry.org Web: www.keyministry.org Twitter: @drgrcevich

2. Learning Objectives: Identify situations where kids may be more susceptible to aggressive behavior during church-based activities Share tools for ministry staff/volunteers to reduce the potential for aggressive behavior in church activities Review strategies for communicating with parents after their child demonstrates aggressive behavior Help parents, ministry staff/volunteers appreciate each other’s perspectives in serving kids with aggressive behavior

3. Subtypes of aggressive behavior: Reactive aggression: Affect: fear, anger Arousal level: high Outcome: negative Impulsive Reactive Defensive Overt Hostile Predatory aggression Affect: self-confidence Arousal level: low Outcome: positive for self Controlled Predatory Offensive Covert Instrumental Vitiello B, Stott DM. J Am Acad Child Adolesc Psychiatry 1997; 36(3) 307-315

4. Definition of maladaptive aggression: Aggressive behavior that occurs outside an acceptable social context Maladaptive behavior is characterized by: Intensity, frequency, duration and severity are disproportionate to its causes May occur in absence of antecedent social cues Behavior not terminated in expected time frame, or in response to feedback Jensen P et al. J Am Acad Child Adolesc Psychiatry 2007; 46(3): 309-322

5. Characteristics of children, youth who exhibit maladaptive aggression: More school adjustment problems than anticipated Higher rates of peer rejection, victimization Difficulty in ambiguous interpersonal situations (reading emotion in facial expressions of others) More likely to read neutral facial expressions negatively Poor peer relationships, deficits in problem solving often emerge by age 4 21% of children with impulsive aggression reported to have been a victim of physical abuse (Dodge, 1991) Dodge KA (1991) In: The Development and Treatment of Childhood Aggression pp 201-218

6. Maladaptive aggression is frequently associated with these common conditions: ADHD Bipolar disorder/SMD/DMD Autism spectrum disorders/developmental disorders Post Traumatic Stress Disorder Anxiety disorders/depression Iatrogenic causes Aggression often co-occurs with specific disorders, but may not be ameliorated by medications used to treat those disorders Jensen et al. J Am Acad Child Adolesc Psychiatry 2007; 46(3): 309-322

7. What situations at church may increase a child’s risk for aggressive behavior (ADHD)? Transition times before and after children’s worship Christian education activities when environment is more chaotic, unstructured, supervision less consistent Following high stimulation, high energy activities Evening activities (no orally administered ADHD medication has been shown to consistently produce effects longer than 13 hours)

8. What situations at church may increase a child’s risk for aggressive behavior (Bipolar)? More reactive to seemingly innocuous stimuli than kids with ADHD Episodic irritability in the context of preexisting ADHD Speech: more, louder, faster More distractible, impulsive, hyperactive

9. Disruptive Mood Dysregulation Disorder (DMDD) proposed in DSM-V: Characterized by severe recurrent temper outbursts in response to common stressors Temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property Response is grossly out of proportion in intensity or duration to the situation or provocation, child’s developmental level Outbursts occur at least three times/week for at least a year in two or more settings Mood between episodes outbursts is persistently negative (irritable, angry, and/or sad) and negative mood is observable by others (e.g., parents, teachers, peers) Chronologic age no younger than 6 (or developmental equivalent), onset by age 10 DSM-V Task Force, American Psychiatric Association, 2011

10. What will kids with DMDD look like? They have ADHD They have difficulty with transitions that violate their locus of control They tend to “ruminate”…indecisive, think too much about things, perseverate…”meltdowns” occur when they get stuck ADHD medication helps in some environments, may exacerbate meltdowns in other environments They don’t do well with down time DSM-V Task Force, American Psychiatric Association, 2011

11. What situations at church may increase a kid’s risk of aggressive behavior: Autism Spectrum Disorders Initial experiences when family first visits church-environment/routine is unfamiliar Changes in routine/unfamiliar people: “buddy” off on Sunday morning, substitute small group leader Excessive sensory stimulation Group situations may be more challenging for middle school, high school youth

12. Three basic assumptions about students in Sunday School/Church: Kids want to be competent, effective learners They feel upset when their behavior gets in the way They fare better when they learn problem-solving strategies

13. A word from one of our experts:

14. Keys to Behavior Management Before During After

15. Before… Pray Create your classroom/respite culture • Encouragement • Expectations Plan proactively • Physical arrangement of the room • Staffing • Content of the lesson • Pace of the lesson • “In the event of an emergency…”

16. During: First line strategies Proximity Control Distraction Hurdle Help Antiseptic Bounce

17. During: Next steps “Grandma’s Law” Emotional Labeling Watch YOUR language Managing other students for safety

18. During: General Rule of Thumb When a child/youth is demonstrating aggressive behavior that is predominantly impulsive in nature, decreasing the sensory stimulation in the environment is generally helpful When a child/youth is demonstrating aggressive behavior that is predominantly perseverative in nature, distracting the child as early as possible before the pattern escalates is generally helpful

19. After: Non-judgmental conversation Problem-solving Quiet Allow for “busy work” Re-join peers Communicate with parents

20. Struggles experienced by families of children at risk of aggressive behavior: Demands on parents may limit time, energy for spiritual growth, much less training their children in the faith Finding quality treatment resources for kids with aggressive behavior is extremely challenging Approved treatments for aggressive behavior in kids with ASD, bipolar disorder have very serious potential side effects ADHD treatments are often associated with effects on appetite, sleep, mood that necessitate medication being withheld on weekends

21. Steps parents can take to enhance collaboration with church staff, volunteers: Do share information with ministry team about techniques shown to help prevent/reduce aggression at home and school Do administer medication shown to help reduce frequency, severity of aggressive behavior during church activities (with approval of treating physician) Do be aware of the concern that aggressive behavior presents in church settings with largely untrained volunteers Doconsider (for the sake of other youth, volunteers) keeping your child at home when he/she exhibits aggression that you can’t successfully manage at home

22. What if a child/youth presents too great a risk of severe aggression to attend church? What can the congregation do to support the rest of the family in attending church, participating in activities key to spiritual growth? Relational (home-based) respite Paid in-home child care/buddies with specialized training Scheduling church activities when appropriate care and support for the child/youth is available Church as resource provider to parent…Whose responsibility is the child’s spiritual development?

23. Conclusions: Kids with reactive aggression can generally be included in existing church programming with appropriate forethought and training Churches may reduce risk of aggressive behavior by designing ministry environments that support kids and youth who struggle to maintain self-control, providing teachers and group leaders adequate training to identify and intervene in potentially risky situations, and by ensuring sufficient staffing at times of enhanced risk Traditional church may not be the “least restrictive environment” for some children/youth especially prone to aggressive behavior

24. Provides FREE training, consultation, resources and support to help churches serve, welcome and include families of kids with hidden disabilities

25. Stay in Touch! Church4EveryChild…Steve’s Key Ministry Blog: http://drgrcevich.wordpress.com Diving For Pearls…Katie Wetherbee’s Key Ministry Blog http://katiewetherbee.wordpress.com http://www.facebook.com/drgrcevich http://www.facebook.com/pages/Key-Ministry/116940088329098 http://twitter.com/#!/drgrcevich http://twitter.com/#!/KeyMinistry http://cmconnect.org/profile/StephenGrcevichMD

26. Questions?

27. Additional Resources: Church4EveryChild…Steve’s Key Ministry Blog: http://drgrcevich.wordpress.com Relational Crisis Prevention and Making Room…Michael Woods http://relationalcrisisprevention.com/ www.makingroom.net/