Stephen Grcevich, MD President, Key Ministry

Assistant Professor of Psychiatry, Northeast Ohio Medical UniversitySenior Clinical Instructor, Child and Adolescent Psychiatry

Case Western Reserve University School of Medicine

2011 Bioethics Conference and Through The Roof SummitCedarville UniversitySeptember 17, 2011

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

Key Ministry, 8401 Chagrin Road, Suite 14B, Chagrin Falls, OH 44023Phone: (440) 543-3400, E-mail: steve@keyministry.orgWeb: www.keyministry.org Twitter: @drgrcevich

Learning Objectives:

Identify situations where kids may be more susceptible to aggressive behavior during church-based activitiesShare 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

Subtypes of aggressive behavior:

Reactive aggression:Affect: fear, angerArousal level: highOutcome: negativeImpulsiveReactiveDefensiveOvertHostile

Predatory aggressionAffect: self-confidenceArousal level: lowOutcome: positive for selfControlledPredatoryOffensiveCovertInstrumental

Vitiello B, Stott DM. J Am Acad Child Adolesc Psychiatry 1997; 36(3) 307-315

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 causesMay occur in absence of antecedent social cuesBehavior 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

Characteristics of children, youth who exhibit maladaptive aggression:

More school adjustment problems than anticipatedHigher rates of peer rejection, victimizationDifficulty in ambiguous interpersonal situations (reading emotion in facial expressions of others)More likely to read neutral facial expressions negativelyPoor peer relationships, deficits in problem solving often emerge by age 421% 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

Maladaptive aggression is frequently associated with these common conditions:

ADHDBipolar disorder/SMD/DMDAutism spectrum disorders/developmental disordersPost Traumatic Stress DisorderAnxiety disorders/depressionIatrogenic causesAggression 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

What situations at church may increase a child’s risk for aggressive behavior (ADHD)?

Transition times before and after children’s worshipChristian education activities when environment is more chaotic, unstructured, supervision less consistentFollowing high stimulation, high energy activitiesEvening activities (no orally administered ADHD medication has been shown to consistently produce effects longer than 13 hours)

What situations at church may increase a child’s risk for aggressive behavior (Bipolar)?

More reactive to seemingly innocuous stimuli than kids with ADHDEpisodic irritability in the context of preexisting ADHDSpeech: more, louder, fasterMore distractible, impulsive, hyperactive

Disruptive Mood Dysregulation Disorder (DMDD) proposed in DSM-V: Characterized by severe recurrent temper outbursts in response to common stressorsTemper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or propertyResponse is grossly out of proportion in intensity or duration to the situation or provocation, child’s developmental levelOutbursts occur at least three times/week for at least a year in two or more settingsMood 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

What will kids with DMDD look like?They have ADHDThey have difficulty with transitions that violate their locus of controlThey tend to “ruminate”…indecisive, think too much about things, perseverate…”meltdowns” occur when they get stuckADHD medication helps in some environments, may exacerbate meltdowns in other environmentsThey don’t do well with down time

DSM-V Task Force, American Psychiatric Association, 2011

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 leaderExcessive sensory stimulationGroup situations may be more challenging for middle school, high school youth

Three basic assumptions about students in Sunday School/Church:

Kids want to be competent, effective learnersThey feel upset when their behavior gets in the wayThey fare better when they learn problem-solving strategies

A word from one of our experts:

Keys to Behavior Management

BeforeDuringAfter

Before…PrayCreate 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…”

During: First line strategies

Proximity ControlDistractionHurdle HelpAntiseptic Bounce

During: Next steps

“Grandma’s Law”Emotional LabelingWatch YOUR languageManaging other students for safety

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 helpfulWhen 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

After:

Non-judgmental conversationProblem-solvingQuietAllow for “busy work”Re-join peersCommunicate with parents

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 faithFinding quality treatment resources for kids with aggressive behavior is extremely challengingApproved treatments for aggressive behavior in kids with ASD, bipolar disorder have very serious potential side effectsADHD treatments are often associated with effects on appetite, sleep, mood that necessitate medication being withheld on weekends

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 schoolDo 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 Do consider (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

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) respitePaid in-home child care/buddies with specialized trainingScheduling church activities when appropriate care and support for the child/youth is availableChurch as resource provider to parent…Whose responsibility is the child’s spiritual development?

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 riskTraditional church may not be the “least restrictive environment” for some children/youth especially prone to aggressive behavior

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

Stay in Touch!

Church4EveryChild…Steve’s Key Ministry Blog:http://drgrcevich.wordpress.com

Diving For Pearls…Katie Wetherbee’s Key Ministry Bloghttp://katiewetherbee.wordpress.com

http://www.facebook.com/drgrcevichhttp://www.facebook.com/pages/Key-Ministry/116940088329098

http://twitter.com/#!/drgrcevichhttp://twitter.com/#!/KeyMinistry

http://cmconnect.org/profile/StephenGrcevichMD

Questions?

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/