For L.A.’s young victims of trauma, intensive therapy seeks to undo the damage

A casual observer watching the preschool-aged children bounce around the outdoor playground at the Children’s Institute campus in Torrance, Calif., wouldn’t immediately notice anything amiss. The children might seem like a rambunctious lot — and why so many adults for so few kids? — but otherwise, it looks a lot like preschool recesses everywhere.

Except that these kids wouldn’t be here had not something already gone very wrong in their very young lives. These are children who have already experienced some kind of serious trauma — physical or emotional abuse, neglect, separation from their parents or other forms of early adversity. More than three-quarters of the kids are involved in the child welfare system, and the stress of the experiences that took them there often translates into all kinds of maladjusted behaviors, with lifelong ripple effects.

In response, programs such as the therapeutic preschool at the Children’s Institute aim to head off the worst effects of such early tribulations with ongoing intensive therapy — four hours a day, five days a week — for months, or even years. Such programs are part of a larger movement in recent years toward “trauma-informed care” as a framework for working with troubled young kids. But it’s not just about the child either. Pointing to the emerging science on how children’s brains develop via interactions with their caregivers, therapists increasingly focus on cultivating the parent-child relationship. Dynamics such as “serve and return” are now seen as critical to healthy child development. “We’re going away, and what we’re trying to leave is not so much a fixed child as much as a resilient family,” Dr. Richard Cohen of the Children’s Institute told 2015 National Health Journalism Fellows during a tour of the nonprofit’s Torrance campus earlier this week.

That’s an ambitious goal. In practice, it can require huge investments of time and resources. “Our children get 20 hours a week of therapy, which is unheard of in an outpatient setting,” said Nicole Fauscette, who supervises the intensive day program at the Institute. “We function like a preschool, so we’re simulating this environment that they’re going to be in for the next 13 years.”

As at a regular preschool, the 3- to 5-year-olds participate in circle time and learning experiences like collecting bugs, and by doing so begin to master control over their bodies. Unlike regular preschool, there’s a small, fully padded “protective separation room” where kids are sent when they need to calm down after they lose control, either mental or physical. “This just illustrates the intensity of some of our kids’ behaviors,” Fauscette said. “This is an absolute last resort.”

Back at the outdoor playground, the goal isn’t just for kids to blow off steam and hone motor skills, but also to develop those crucial “executive function” and self-regulation skills needed to succeed in school and work. Catching a bug in a cup seems basic, but it requires a series of traits — patience, persistence, physical discipline, composure — that are often conspicuously lacking in kids that have undergone neglect or abuse. “Every moment is a therapeutic moment,” Fauscette said.

The need is immense. Los Angeles County has the largest child welfare system in the country, with over 31,000 open cases and 12,000 calls a month to the county’s child abuse hotline. According to Cohen, 40 percent of those open cases are kids 4 and under, and 40 percent of that subset are 1 or younger.

Many of those kids have unaddressed mental health needs, and it’s the job of psychologists such as Dr. Julia Esqueda-Arteaga to try to identify some of those budding problems as early as possible. Esqueda-Arteaga supervises children’s assessments at the Children’s Institute, which works with the Department of Child and Family Services and the next-door Harbor UCLA Hospital to evaluate kids entering the child welfare system. (Kids entering the foster system for the first time must undergo a court-ordered assessment.)

“It’s really important for us to get these children assessed early and do it really fast,” Esqueda-Arteaga said. Such assessments can help social workers better understand how to handle a child’s case and eventual placement – either returning to the family or in foster care – and can pinpoint overlooked mental health issues in need of early therapy.

Esqueda-Arteaga’s team will often go the family’s home and explore first-hand the family’s living conditions. “From the moment we walk in the door, we’re asking, ‘Where do they live? What do they have access to? Are there toys here?’”

From there, Esqueda-Arteaga and her colleagues put together a plan for the family, which might entail parenting classes, Head Start for the kids, therapy for mom, cleaning up the house, one-on-one therapy for each child and so on -- but not necessarily all at once.

“The whole end goal for us is to come up with a treatment plan, with a timeline,” Esqueda-Arteaga said. “Once you meet the family and go out into their homes, you really need to very sensitive about what’s realistic for this family.”

One common treatment for parents struggling to connect with their child is called Child-Parent Psychotherapy (CPP), an approach fellows heard about repeatedly this week. While the practice dates back to the 1980s, it has been increasingly embraced in recent years as part of the larger shift in how mental health professionals approach kids and parents, according to Cohen.

Therapists increasingly talk about a child’s attachment to the parent and “strengths-based” approaches. CPP entails relating to parents in a different way: rather than chastising bad parenting behaviors, therapists are now taught “to come alongside parents, watch the child, and think about what we could do,” said Cohen. “It’s a huge shift, and it works even within the child welfare system.”

For Bryana Servedio, a therapist at the Institute, that approach is central. By way of illustration, she recounted the story of Perla, a mother of six kids who repeatedly cycled in and out of the foster care system from 2008 to 2015, when the family’s case was finally closed after the mother completed an extensive list of programs and therapy. The family’s long ordeal included bouts with drug addiction, alcoholism, domestic violence and school truancy.

In working with the family, Servedio made routine visits to their home, where she would gently coax Perla toward a deeper, more empathetic understanding of her children’s behaviors.

“I’m standing side by side with Perla and actively wondering with her, ‘What could be the meaning behind her child’s temper tantrum right now?’” Servedio explained. It’s an approach that can lead to breakthrough insights for parents, and potentially restore those all-important parent-child bonds, experts say.

It can also make it less likely children have to undergo the trauma of being removed from their homes and shunted through foster care. On that point, the research is counterintuitive, said Cohen. “You would think if you could put them with a nice, comfortable, middle-class family, the kids will do better. But the research actually says that the kids do better when they can stay at home.”

[Photo by Martha Shirk]