Clients’ Children: How Can We Support Them?

1. SYNTHESIS, INC. 395 E. Broad St., Suite 100, Columbus, OH 43215 (800) 322-9441e-mail: synthesis@synthesisincohio.com Clients’ Children: How Can We Support Them? Using Cluster-Based Planning to Create Pictures of Youth and Their Families

2. WHAT IS A CLUSTER? A Cluster is a subgroup of a larger clinical population that shares common strengths, problems, treatment histories, social and environmental contexts, and/or life situations. Clusters represent more holistic bio-psychosocial pictures of patterns of behavior. They represent the interaction of an individual’s mental and/or physical condition with his/her environment over an extended period of time.

3. WHAT IS CLUSTER-BASED PLANNING AND OUTCOMES MANAGEMENT? Cluster 1 Children/Adolescents Who Have ADHD Or Other Neuro-Behavioral Conditions Cluster 4 Children & Adolescents Who Have Been Sexually, Physically, Or Emotionally Abused SERVICES SERVICE GOALS OR OUTCOMES RESOURCES

4. How Were Clusters and Outcomes Developed? • Step 1: Identifying Clusters Of Chemically Dependent Homeless Women and Their Children. Expert workgroups comprised of administrative , clinical staff and outside providers (for youth) were established. Consultants employed a group knowledge elicitation process to collect information from the experts about prototypical individuals and their common characteristics, problems, strengths, and life situations of subgroups of clients being served. To construct the youth clusters, text from previous planning efforts was used as stimuli. • Step 2: "Painting Prose Pictures" And Validating The Narrative Cluster Descriptions. For each cluster, the descriptive information from the knowledge elicitation process was summarized in a prose draft cluster description. The workgroup then reviewed and revised each draft, and agreed upon the text of the Final Cluster Descriptions. • Step 3: Determining Core Service Outcomes Or Treatment Goals For Each Cluster. The Final Cluster Descriptions were then used as stimuli in a group process called an "Intention Analysis." Looking at each cluster independently, members of the workgroup were asked first to identify what they would like to have happen in the lives of the members of the specific cluster. These “intents” of treatment were interpreted as treatment goals or outcomes. Workgroup members were then asked to describe what it would look like when a person was “doing well” on a particular outcome and when they were “doing poorly” on that goal. Consultants used this information to develop scales specifically tailored for each cluster and anchored by the information provided by the workgroup about each outcome.

5. More Mature Women Who Abuse CRACK Younger Adult Women Addicted To CRACK Cocaine CLUSTERS OF WOMEN SERVED BY AMETHYST, INC. Women Addicted To Prescription Drugs Substance Abusers With More Severe Mental Health Problems More Mature Women Who Abuse Alcohol

6. SAMPLE ADULT CLUSTER DESCRIPTION Cluster 1 MORE MATURE WOMEN WHO USE AND ABUSE CRACK COCAINE The women in this cluster are facing major life crises as a result of their addiction to crack cocaine. Many have long histories of abuse of alcohol or other substances. Most have tried to kick their other addictions several times but have always relapsed. They have been using crack for several years, and the dependency for this drug has taken over their lives resulting in a significant downhill slide. Many have or are at-risk of losing their homes, their children, and their jobs. Over the years, they may have “sold their bodies for drugs,” or have been arrested for drug trafficking, writing bad checks, shoplifting, or assault. Many cluster members have been involved in a series of destructive relationships, and have been physically and/or sexually abused. Relationship dependency and abuse often become long-term treatment issues for many of them. The addictive behavior of many cluster members has become more serious over the years. They began using alcohol or other substances as teenagers. Many dropped out of high school, some as the result of teenage pregnancy. They may have received mental health counseling but their addictive behavior was never identified. Besides alcohol, marijuana, and other “street drugs,” some have become addicted to prescription drugs and have manipulated hospitals and doctors to get the medications. Their parents, spouses and friends have also abused drugs. They began using crack because of the progression of their disease and the availability of the drug. However, most cluster members have great difficulty understanding the relationship between their past and ongoing substance abuse and their more recent addiction to crack .Members of this cluster feel trapped by their past life choices. They see others their age who have succeeded and they are ashamed of their own material and spiritual failures. Many want to make amends for past actions or omissions. They feel trapped between their parents who also have lived dysfunctional lives, and their children. They see themselves repeating their parent’s behavior and they see themselves in their own children. They feel anger, guilt, and shame all at once. For years their lives have barely been in control, and finally it has become a matter of too many years, too much “stuff” and nothing to hang on to. Many feel a sense of hopelessness and despair. Many members of this cluster have limited education or vocational training. They fear work settings and even those with more education lack the confidence to work in their chosen field. Thus most will take any job they can get and have been “under-employed,” if employed at all. Not unexpectedly, members of this cluster have constant financial problems and frequently have needed public support for food or shelter. However when women in this cluster accept their addiction, many of their painful feelings can become strengths to support their treatment. Being more mature, they have experienced more life consequences from their addiction, and may even have exhausted their “enabling” support systems. Their past lives may provide religious, spiritual, and social values on which to “fall back.” Their desire to rebuild their lives often enables them to reach out for help, and to follow-through with what they need to do in recovery.

7. CLUSTERS OF YOUTH IN NEED OF MENTAL HEALTH, SUBSTANCE ABUSE, OR OTHER SUPPORTIVE CARE Cluster 1 CHILDREN AND ADOLESCENTS WHO HAVE ADHD OR OTHER NEURO-BEHAVIORAL CONDITIONS Cluster 2 CHILDREN AND ADOLESCENTS WHO ARE DEPRESSED AND/OR SUICIDAL Cluster 4 CHILDREN AND ADOLESCENTS WHO HAVE BEEN SEXUALLY, PHYSICALLY OR EMOTIONALLY ABUSED Cluster 3 CHILDREN AND ADOLESCENTS WITH SERIOUS BEHAVIOR PROBLEMS Cluster 6 CHILDREN AND ADOLESCENTS WITH SUBSTANCE ABUSE ISSUES Cluster 5 WITNESSES OF CHRONIC TRAUMA Cluster 8 INFANTS AND TODDLERS WITH EARLY DEVELOPMENTAL AND BEHAVIORAL DIFFICULTIES Cluster 7 ANXIOUS CHILDREN

8. CLUSTER 5 WITNESSES OF CHRONIC TRAUMA The children/adolescents in this cluster have suffered a series of traumatic events in their lives as a result of living with a parent who is chemically dependent. Examples of these events include: witnessing domestic violence--sometimes involving guns and knives, moving from one caregiver to another, the serious physical or mental illness of a caregiver, the death of a caregiver, witnessing their parents being taken to jail, and/or witnessing their siblings being taken away. Members of this cluster feel great loss and fear, and/or feel guilt for having survived the trauma while others did not. Over time, cluster members begin to experience "flashbacks," depression, become withdrawn, experience panic attacks or phobias, lose their sense of trust in adults, become very demanding, or become angry and "act out" against the world. Often they have problems sleeping. Some may have nightmares about the events or suffer sleep deprivation because of the fear of having the nightmares. Some may develop serious eating disorders such as anorexia or bulimia. Many blame themselves for the outcome of the traumatic events, experience increased anxiety or agitation, are often hyper-vigilant, and prefer not to be around others. For many members of this cluster, the impact of the traumas can be pervasive, and affect many parts of their lives. However, depending on the specific traumatic event and how they perceive it, cluster members may respond in different ways. Younger children, for example, may show even more infantile behavior, experience nightmares, and develop irrational fears (phobias). Sometimes because their anger or fear is so intense, they may seem to "shut the world out" or they may even become mute. School-age children may become clinging and dependent, may act out in school, or even make attempts at suicide. For other children, the traumas cause them to lose trust in the ability of adults to protect them or others from harm. Their sense of security is shattered and at the same time, they feel guilty about surviving the traumas. They seem to "grow up fast," and may begin to live life only for today. If the traumas involved loss of a sibling, close friend, or trusted adult, it can influence their ability to form close relationships. Some members of this cluster may become very critical of themselves and overcompensate by trying to be perfect in order to keep bad luck away. Some may take on the caretaker role in the home. Others may attempt to punish themselves for surviving the traumatic events. Some of the pre-teen and adolescent members of this cluster become angry and frustrated with the world. They may feel that "bad things don't happen to good people, so why did it happen to me." They may have outbursts of anger, and gravitate toward other "negatively oriented" kids, or kids with similar situations. They may begin to self-medicate with drugs or alcohol in order to help them cope with the past traumas. They don't want to talk about traumatic events that have happened in the past, and may deny the impact those events have on their lives. Some cluster members are able to find a positive, "safe" adult who believes in them and with whom they can establish a trusting relationship. This may be a counselor, family friend or relative. Through this relationship they may develop a sense of resilience and begin to deal with the effects of their life situations. However, when this is not the case, the children begin to act out, and are often referred to the court or mental health system. Early in their recovery, mothers of cluster members may have difficulty recognizing the trauma their children have faced by witnessing the violence, abuse, and loss occurring around them. As a result, the needs of cluster members may initially be overlooked. However, as mothers progress in their recovery and gain insight and awareness of the traumas their children have faced, they begin to establish new rules, roles, and rituals within the family. This provides greater safety and stability for their children.

9. SAMPLE OUTCOMES FOR MEMBERS OF YOUTH CLUSTER 5WITNESSES OF CHRONIC TRAUMA PLACING RESPONSIBILITY ACCURATELY FOR THE TRAUMATIC EVENTS Some children really understand who is responsible for the violence, abuse, or other traumatic events. They acknowledge the events and they stop believing they could or should have done something to prevent them. They stop feeling ashamed about their lack of ability to stop the events. They recognize they were only a child and did not have the power to prevent the events. They recognize who or what was actually responsible and can identify that person or situation. They can focus on the fact that they did not cause the traumatic events. They feel less guilty for having survived or avoided being victimized, and feel comfortable being around the victims. Other children inappropriately believe that they could or should have been able to prevent the violence, abuse or other traumatic events. They may deny or minimize the importance of the traumatic events. They believe they should have and could have prevented or stopped the events. They feel great guilt for having survived or avoided the abuse or trauma, and may have difficulty being around those who were victimized. They may take out their anger and frustration on other children, animals, objects, or themselves. Some may focus on something they did or did not do that they feel kept them safe while others were being victimized. They may then exaggerate the characteristic in order to keep themselves safe in the future. For example, they may try to be very quiet or very “good.” They may feel they need to take responsibility for nearly everything. How Well Does The Child/Adolescent Accurately Place Responsibility For The Violence, Abuse Or Other Traumatic Events? REDUCE INTERFERENCE FROM HIGH-RISK AND SELF-INJURIOUS BEHAVIORS The fact that members of this cluster have lived through or avoided abuse, violence or other traumas makes them feel uncomfortable with their own survivorship. Many engage in high-risk and self-injurious behaviors that can interfere greatly in their lives. For example: They may take dares from other children and take unnecessary risks. They may appear to have a sense of invincibility and may test themselves by putting themselves in dangerous situations to see if they can survive. They may place themselves at risk because they feel they deserve to be hurt (because they survived past traumatic events).Because adults perpetrated the violence or failed to protect others, they may have lost trust in adults in general and resist their authority. They may take out their anger or frustrations on other children, animals, property, or themselves. They may become involved with the criminal justice system. They may try to work through the trauma they witnessed by playing out what happened and what they would have done. They may try to get away with doing things they know are wrong, and because of their survivor guilt, may want to get caught so they can be punished. They may make plans for and/or attempt suicide. How Much Do High-Risk And/Or Self-Injurious Behaviors Interfere With This Child’s/Adolescent’s Life?

10. SAMPLE OUTCOMES FOR MEMBERS OF YOUTH CLUSTER 5WITNESSES OF CHRONIC TRAUMA PARENTAL SUPPORT FOR CHANGE IN THE CHILD Some parents provide an environment that supports the changes the child/adolescent needs to make. They do not deny that the violence, abuse, or other traumatic events occurred. They take responsibility and acknowledge that their child and/or family were not protected. They recognize the impact that witnessing the events has had on their child. They provide a safe home environment. They do not hurt or abuse their child or allow others to do so. They do not blame or shame the child for the events, or minimize the impact of the events or defend the perpetrator(s). They assure the child they were not at fault and that they did not have the power to stop the violence or other traumatic events. They give their child affection and nurturing support and help them understand they should not feel guilty for having avoided or survived the abuse, violence or other traumatic events. They provide opportunities for their child to talk about the traumatic events and their feelings about them. They talk about their own feelings and encourage their child to talk about theirs. They arrange for counseling and see that the child keeps appointments. Other parents do not provide an environment that supports the changes the child/adolescent needs to make. They do not take responsibility for their child/family not being protected. They do not provide a safe home environment. They may deny or minimize the fact that the traumatic events occurred. They deny or minimize the impact the witnessing of the events has had on their child. They may not give their child affection and nurturing support. They may make the child feel guilty for having avoided being victimized. They may continue to hurt or abuse their child or allow others to do so. They may defend the perpetrator(s). They may not provide opportunities for their child to talk about the traumatic events, their survivor guilt, and other feelings. They seldom share their feelings and do not encourage their child to talk about his/her own feelings. They may not arrange for counseling or may not insure that the child keeps counseling appointments. They do not help their child develop social skills and positive friendships. They do not help their child feel good about themselves How Well Do The Parents Provide Support For Change In Their Child? SEPARATION OF OWN EXPERIENCES FROM THAT OF HER CHILD Some parents are able to separate their own experiences of the traumatic events from those of their child. They talk about their own feelings and encourage their child to talk about theirs. When they are having trouble dealing with their child’s issues, they provide other opportunities for the child to talk to someone else about the problems. They arrange for counseling and see that the child keeps counseling appointments. If they are in recovery from abuse themselves, they are able to separate their own feelings, issues, and treatment process from those of the child. Other parents have difficulty separating their own traumatic experiences from those of their child. If they were themselves victims of violence, abuse, or other trauma, they may have difficulty separating their own feelings and experiences from those of their child. They seldom share their feelings about their own experiences, and do not encourage their child to talk about his/her own. They may not arrange for counseling or may not insure that the child keeps counseling appointments. If they do, they may try to dictate their child’s therapy based on their own treatment experiences. How Well Does The Parent Separate Their Own Experiences Of Traumatic Events From That Of Their Child?

11. NEXT STEPS: • IDENTIFY FAMILY CONFIGURATIONS AND • DEVELOP FAMILY-BASED SERVICE PLANS THAT TAKE INTO ACCOUNT THE RELATIONSHIP AMONG THE MOTHER’S CLUSTER, THE CLUSTER(S) OF HER CHILDREN, AND HER RECOVERY PROCESS