Good Controls for Children

by CAROL DUKOFF

How do you restrain an emotionally disturbed child who has temporarily lost his self-control? What method can you use that will maintain safety but which will not further damage the fragile ego of the child? In the article below, based on seminars held with Browndale therapeutic parenting staff, Carol Dukoff discusses the philosophy and technique of physically "holding" a child who has temporarily lost control, a method developed by Browndale's founder, John L. Brown. Carol Dukoff's many years' experience at Browndale includes the positions of therapeutic parenting staff, house head, member of the resource staff and regional director of the Newmarket Region of Browndale (Ontario) from 1973 until 1976; she is now Senior Child Care Resource Staff for Brown-dale (Ontario) on call to the directors and resource staff of every Browndale region in Ontario.

Every treatment centre for emotionally disturbed children must decide how to restrain children who temporarily lose their self-control so that they won't hurt themselves or anyone else. At Brown-dale we use a method which we call "holding" which was developed by founder John L Brown while he was working with the Detroit Group Project with Dr. Fritz Redl. If a child becomes so upset that he loses control, the staff stay with him, holding him firmly so that he can yell and scream as loudly as he wants but he cannot move. This allows the child to ventilate his rage in a safe way.

For the child, this is an experience very different from being isolated or drugged. A child shut up by himself in a "quiet room" — often devoid of any furniture — experiences this as a rejection of his feelings and himself. He may scream and cry himself into a state of exhaustion but he will do it alone with no one to share the pain; not until he's quiet will he be allowed to be with people again. A child given a strong tranquillizing drug will wake up to the same unresolved problems, his anger suppressed, not released. Methods like these may bring temporary relief to the staff but they do not benefit the child.

We say to the children who come to Browndale, we accept you and your feelings. However much rage you have inside you we can handle it. We won't let you, in your anger, hurt yourself or anyone else or do any damage to the property. If you lose control we will stay with you and hold you and keep you safe until you are relaxed and calm again, in this way, we show the child by our actions as well as our words that we care enough for his well-being to involve ourselves in keeping him safe. So the principal reason for a "holding" is safety; a secondary benefit is the release of pent-up anger which brings a relaxation of tension that enables the child to go on to focus in on other things. One of the most important aspects of holding from the point of view of treatment is that it is not punitive; it is a technique that allows safety to be maintained within the context of relationship with other people.

There are, basically, two different types of holdings. It is always preferable for the staff person who has the closest relationship with the child to be involved in the holding. But sometimes a child may lose control when that person is not around and then another staff must step in, in much the same way that any adult — seeing a child in danger — would intervene. The emphasi? in this type of holding is on preventing the child from doing something that would be harmful. Although the staff may say to the child, you may not throw ashtrays, or hit another child, or whatever, there will be little or no probing into the reasons why the child is angry; that may be done later with a staff more deeply related to the child. If, however, the child is being held by a staff person with whom he has developed a close relationship, the security of being held may enable him to express anxieties and frustrations that he has not been able to share with anyone before. Together, staff and child may be able to get at the "guts" of what is really upsetting the child, something that can be worked through later. This type of holding can be an important step forward in the treatment process.

Children don't always know why they are angry. If a staff knows a child well, he may be able to make some informed guesses. He may be able to say.

I think perhaps you are upset today because such-and-such happened . . . and something may click with the child, enabling him to make a connection he hasn't been able to make before. However, staff should not expect every holding to have this kind of resolution and if they push too hard with the "whys" and the "how comes" the child may make up something just because he feels an explanation is expected of him.

We need to watch we don't slip into a battle of wills thinking that because the child is being held he must "come through" with something. If it becomes obvious that the holding is getting nowhere but the child appears to have his controls back, the staff might simply say something like, look, we don't seem to be getting anywhere, why don't we go into the kitchen and I'll get you a glass of milk; I'll still be around if you need to talk to me later on. Then the staff can gradually release their hold on the child, being ready to resume control if they have misjudged the situation. The child should not, at this point, be allowed to go out of the house, or up to his room by himself. The staff might say to him, I want you to be close to me for a while because I know you aren't feeling that great just yet. In our small therapeutic family houses we expect staff to be aware of all the children in their care at all times; when staff are not sure exactly how a particular child is feeling it is even more important to be aware of the child, even to the extent of keeping him in sight.

I think that what happens directly after any holding is almost as important as the holding itself. We never say to a child who has just been held, okay, that's over, you can go and do your own thing now. We might help him wash his face or change his shirt; we might get him something to eat or drink. We should always let him know that we are close by, still available if he needs us. A child who has been held needs to be reassured that although he has expressed a great deal of anger he is still accepted, still a valued member of the therapeutic family and he can gain that reassurance through our attitude toward him and our actions.

The primary purpose for holding a child is to maintain safety and in order to make things safe for both child and staff at least two staff should be involved in every holding. Even if the child is small enough to be held by one staff, another staff should be in, or in and out of the room. We expect our staff to be in control of their anger but staff are human and having someone else around ensures that even if the child's behaviour is making us very angry at that moment, the focus will be kept on the needs of the child. A child should be held because he is angry, not because the staff is angry. If a staff in a house thinks one of the other staff is a little off in focus, he should go over and say something like, can I be of any help?; or, would you like me to take over here for a while? Staff working together should develop some recognizable signals for times like these and they should talk it over afterwards if they think a situation wasn't handled the right way. You might be right or you might be wrong but share your concern, tell the other staff how things looked to you.

The child will feel safer if another staff is involved, especially if the staff who isn't directly involved plays the role of the child's advocate saying something like, Johnny, you sound as though you are feeling angry at Mike, why don't you tell him what's bugging you? If both staff are yelling at him, the child will feel as though everyone is ganging up on him and he hasn't a friend in the whole world; but when he sees that one of the staff isn't angry and is really trying to see things from his point of view, the child will find it easier to express his anger and the freer the child is to express his anger verbally the less is his need to act it out in destructive or harmful behaviour.

With a bigger child it is essential to have more than one staff physically involved in the holding to make it safe. If you are alone in the house and you sense one of the children might need to be held before long, get on the phone to one of the other houses and ask them to send over one of their staff. In the meantime, you might have to walk on eggshells for a while. Don't push him on things you might normally pick him up on; otherwise you may end up in a brawling match in which one or both of you might get hurt.

The easiest way to hold a small child is in an armchair with the child sitting between your legs so that he is on a lower level, and at a slight angle; then if he brings his head back it will hit your shoulder rather than your face. Cross his arms over his chest and hold his wrists out so that he can't scratch you and place one of your legs over his legs so that he can't kick. With an older child it is easier and safer to sit on the floor with your back supported by a wall. Hold the child in a sitting up position, again at a slight angle, and cross his arms over his chest. Another staff should hold his legs and it may be necessary to have a third staff involved if the child is big and strong.

If staff get hurt in holdings it is usually because they don't know how to hold a child properly or because they haven't moved in fast enough and as they become more experienced they shouldn't get hurt. It comes back to knowing the children in your care well enough that you can anticipate their reactions. When you are going to hold a child you need to move with great speed and precision to bring him under control quickly.

If a child does manage to hit or bite you, let him know that he's hurt you but don't yell at him for the next 15 minutes because you weren't holding him securely enough. After the holding, get the bruise or bite looked after and let the child know that it is being treated and is getting better. Don't add to the child's guilt by walking around displaying a bruise or a bite, or with your glasses held together with tape for the next three weeks (giving the child the double message, what happned wasn't your fault, see what you did to my glasses! We say to children who come to Browndale we will make it safe for you to express your rage and if a staff person gets hurt we have not done what we promised we would do and we cannot shift the responsibility onto the child. If you find yourself constantly getting hurt in holdings although you have been shown the safe way to hold a child you need to think about whether you are unconsciously setting yourself up to get hurt.

Always be sensitive to the feelings of the child being held. If a girl's skirt rides up, or a boy's fly comes undone, look after it so that they don't have to worry about it. A female staff should always be the principal person involved in a holding with an adolescent girl and a male staff with an adolescent boy. Sometimes young adolescent girls try to set up holdings with their male staff but when that happens the female staff should go in and take over the main part of the holding, although the male staff may stay on to help make it safe.

Disappointment and anger are never justification for dangerous behaviour

Try to make the child as comfortable as possible in the circumstances; if the child is being held on the floor, you might ask another staff or one of the children to get you a pillow or a cushion to put under his head. However, if you know you are holding the child in the correct position, don't let him sidetrack you with complaints that his arm hurts, or he can't breathe. If he succeeds in getting you to spend the next 20 minutes discussing whether or not you are hurting his arm instead of the fact that it is not okay to throw ashtrays, he is in control of the holding. Say to him firmly, you're okay, Johnny, I'm holding you safely, and return to the point at issue. Neither should you let a child sidetrack you by offering excuses for what he did. The sequence of events that led up to the outburst may be discussed later, but don't allow the child to confuse the issue. Disappointment and anger are never justification for dangerous behaviour; the child has to learn to live with these feelings and replace the behaviour with words.

... it is important for the other children to be able to see for themselves what's going on.

At Browndale, we learn to share our feelings and we never isolate the child being held. That would give him the message that he is a "bad" child who should not be with other people. The child gets held where he needs to be held and it's okay for the other children to be around. In fact, it is important for the other children to be able to see for themselves what's going on, particularly if they are new to the program. The child being held may be yelling, you're breaking my arm, I can't breathe! The holding needs to be out in the open so that the other children can walk by and check out what's going on. But they should not be allowed to interfere. You might say something like, Johnny's being held Mary and you can see that he's okay, do you mind getting me a cloth to wipe his face; or, why don't you play a game of cards with Derek; or, how would you like to start peeling the potatoes for supper? In the meantime Johnny may be screaming, I'm not all right, she's killing me, hit her on the head! But Mary can see that Johnny is okay and our children soon learn that the staff do not hurt them.

I remember, some years ago, I had to hold a girl who lost control while the house was being visited by an older woman, a social worker from an outside agency. The older children in the group took charge of the visitor, reassuring her that Mary was fine, she wasn't being hurt and that they knew that because they had all experienced being held themselves.

... we won't hurt you here, we don't hit you and we don't give you needles.

When a new child came into a house I was responsible for, I used to explain to him on his first day what a holding was so that if, later on, one of the children in the house had to be held he would understand what was happening. I'd tell him, we won't hurt you here; we don't hit you and we don't give you needles. If at any time you lose control and are hurtful to yourself or anyone else we will hold you to keep you safe. And with a small child I'd take him on my knee and show him exactly how we would hold him.

Some staff become very upset if the child they are holding spits at them and they put their hand over the child's mouth to stop it, which I regard as a terrible violation of the child. I had one staff tell me, I just cannot tolerate it, I'm afraid I will vomit over the child, and I suggested she hold her hand in front of the child's mouth (not over it) so that the spit hits her hand instead of her face. But the feeling of revulsion will be less if we can come to understand what spitting means to the child. Spitting is a form of communication and may be the only way the child can communicate with you

at this point in time. I like to ask staff to put themselves in the position of the child. If you were enraged and were being held so that you were unable to move, what would you do? There's not much you could do in that kind of a situation except scream, swear or spit. If you chose to spit, what would you be communicating? Anger, hostility, the feeling that even though you are immobilized you cannot be totally controlled. It can also be that the child, in his anger, does that which he thinks will hurt or annoy you the most. When it doesn't, he will stop; either because what he is doing is ineffective, or because you have accepted him and his feelings, even when he has done what he thinks is the worst thing he can possibly do to you. John Brown believes that spitting is really a request for communication on a very primitive level because, in essence, what the child is doing is taking something from inside himself and giving it to you.

Let him get his anger out, whether he expresses it in words, screaming or wailing.

Staff also need to be aware of how they react to having a child yell, scream or swear at them. It can be hard to take if you take it personally and you may find yourself trying to stifle or curtail the expression of the anger. Remember, it is no good telling a child it's okay for him to yell when he's angry if you start to talk or yell at him every time he opens his mouth. Let him get the anger out, whether he expresses it in words, screaming or wailing. It will be easier to take if you can keep in mind that you are not the target of this accumulation of rage; an angry child will displace his rage onto the first adult who loves him, cares for him and makes him feel safe.

New staff sometimes become upset when a child they have been establishing a nice, warm relationship with suddenly starts to become uncooperative and to say nasty things to them. This can be very hard to take if they take it personally; they often start to worry about what they did or said to cause the abrupt change in behaviour. What they don't realize is that the child is testing them; is saying, in effect, you've accepted me during my nice times, can you accept me when I'm angry, too? When a child begins to feel comfortable and safe, he will start to express some of his anger and hostility. Many times in the past, other people have not been able to accept the negative behaviour and the child, at that point, has been shipped off to another foster home, group home, hospital or institution.

So the anger got suppressed and was released later through acting out or rebellious behaviour

It's not easy to deal with a child's anger because we all grow up in a society that teaches us that it is not okay for a child to get mad at, to yell at, or even "answer back" an adult. It is right that children respect adults, but many of the children who come to Browndale have come from homes where it was not okay for them to express what they were feeling. Any time they've gotten angry and shown it, they have been sent to bed without supper, or punished in some other way. So the anger got suppressed and was released later through acting out or rebellious behaviour like stealing, lying, breaking street lights or kicking over garbage cans. If we are going to help the children who come to Browndale, we have to provide them with responses and experiences that are different from those they have been used to. We've grown up in the same society and so we need to be aware of our responses, to make sure we are not cutting the child off, or penalizing him, when he does begin to feel secure enough to start ventilating some of the repressed anger. We are assigned the task, when the child is sent to us, of helping the child convert his rage into socially acceptable behaviour, but we cannot do that by denying the rage. A service that cannot allow the child to express the rage that is in him should not take enraged children because they cannot be helped unless the rage is allowed to be released.

We place very high expectations on the children at Browndale that they do not act out their anger, fears, anxieties and frustrations outside the house. They soon come to know and accept that the house is a safe place to have a "hard time"; that we will not tolerate acting out or socially unacceptable behaviour in the community. This is just the opposite to what happens in many families in the community where the children are "seen and not heard" — or, more important, not listened to. I really believe there would be far less delinquency if families could allow their children more open verbal expression and really listen to what their children are trying to tell them. It is very, very rarely that a Browndale child is involved in any act of delinquency in the community; this is partly because the Browndale staff are expected to know where their children are at all times and be aware of how they are feeling and partly because we allow the children to give verbal expression to their anger in the houses so that they don't need to take it out into the community.

Both staff and children know that if a child swears or otherwise behaves badly on an outing, the whole family group will have to return to the house. In this connection, the staff carry a major responsibility in that before they take any child out into the community they should know whether or not he's in good shape for the trip. I think every staff has probably had the experience of planning an outing and thinking, Mary's okay, Johnny's okay, but I'm not sure about Harry — I hope he'll be all right. Five miles from home Harry's having a hard time and everyone has to come back. The other children are mad at Harry because he spoilt the trip, the staff are mad at Harry and yet, really, who is to blame? If a staff has some doubts about whether one of the children is ready to go out into the community he should spend an extra 15 or 20 minutes, whatever time may be necessary, helping the child get ready for the trip.

We talk a lot about allowing the child to ventilate his anger but we shouldn't forget that staff need to let off steam too, at appropriate times and in appropriate places. It's a responsibility of the supervisory and resource staff to see that the therapeutic parenting staff get these opportunities and it is the responsibilities of the therapeutic parenting staff to get to someone to talk things over when they are feeling frustrated and angry. And if something in your personal life has upset you and you go into work feeling angry or anxious, share tha with the other staff; say, look I'm not feeling that good right now and i'd like you to be aware of me so that I don't go taking it out on the kids. There have been occassions when I've found myself mouthing off at a child for reasons that have more to do with me than him and I've stopped and said quite directly to him, look it's not you I'm angry at, there are other things going on in my life and I'm not feeling that great today. As you become more aware of our own feelings it becomes easier to do that. And I believe it is helpful to children if adults are honest with them about their feelings. Adults rarely are and it can be confusing for a child whose mother yells at him one day for something that was okay the day before. It would be better for the child if the mother could say, look I can't stand you doing that right now because I have a headache, or Im worried about your grandmother, or whatever.

If you find yourself continually holding a certain child who dosen't get held often by other staff you might ask yourslef, what does that child mean to me? What person out of my pastdoes that child remind me of? Resource sataff can often help you look at a situation in your therapuretic familymore objectively. Because they drop in from time to time they gte a different perspective of the child and can somethies recognize a situation that someone working with the children day by day misses.

After every holding staff should sit down and assess why it happened and wether it could have been avoided. Wasss htis child giving out signals earlier that weren't picked up? Did he have a hard time getting out of bed that morning? Or getting to sleep the night before? Was he having problems at school that day? Perhaps if staff had been able to help him around that, the holding might not have been necessary. The purpose of this type of assessment is to help staff gain a better understanding of the child and the kind of signals he gives when he needs help around handling his feelings. It needs to be done with the hosue head at least ansd someone should be called in from the resource staffif additional help is needed. The regional director should always know when there has been a holding in a house in his area.

I do not not mean to suggeat that holdings are never necessary; holding is a treatment technique that can be helpful for some children. It is not beneficial. however, for everychild that comes into the treatment center. Often holdings can be avoided as staff become more sensitive to the feelings of the children and help them deal with their fears,anxities and frustrations before the tension acculates to the point where the chil loses his self-control.

I remember two simple diagrams that John Brown used to draw in staff seminars which I attended. One showed tension building up inside a child until it reached a peak, causing an explosion of rage which resulted in the child having to be held. The other diagram showed anger being released in little spurts at frequent intervals so that it never did build up to a point where the child lost control.

A lot of the anger can get released around whether or not the child should hang up his coat . . .

One of the best ways of helping a child release anger is the sensitive use of "anchor points", a method developed by John Brown after careful analysis of exchanges he observed in families in the community and described in detail in "Routines, Limits and Anchor Points"*. Most families have certain rules of behaviour known to the children which are based on good health practices or common sense but which are not life essential. Some examples are hanging up your coat when you come into the house, wearing shoes or slippers around the house, not putting your elbows on the table during mealtimes. If a child wants to engage an adult he can break one of the rules. A lot of anger can get released around whether or not the child should hang up his coat and while the argument is going on the staff can continue preparations for supper or do whatever else needs to be done at that moment. Because none of these "rules" are life essential the staff can let the child "win" the argument if that is what his ego need is at that particular moment. Sensitively used, anchor points can be a flexible treatment tool.

There are, of course, many other ways a child can let off steam — a session with a punching bag, a game of tag in the yard, or a friendly wrestling match. Sometimes a child just needs diverting; you may be able to head off a potential problem by playing a game with him, or suggesting some activity he might enjoy.** Sometimes staff who do not have a great deal of experience hold children out of their own anxiety. Children don't need to be held every time they get angry, only if they lose, or are about to lose control. Sometimes all that is needed is what I call a "containment". If you know a child well enough you can sense when he's working himself up to the stage where he might do something harmful and you may just need to say something like, hey, slow down, or hold his arm for a moment or two, or do whatever else will help that particular child maintain control over his feelings. Again, it comes down to knowing the children in your care; some children might feel threatened if they were touched, others would find your hand on their arm reassuring.

Some children get into regular holding sessions when they first come into Browndale because it is the only way they have learned to get attention. They may come from homes where the adults are so harassed and preoccupied with their own problems the children get little attention unless they misbehave. Then the parents may overreact and punish them severely. Afterwards, feeling guilty, they may make a big fuss of the child, even buy him a gift. If this is the pattern of adult behaviour the child is used to, he m'ay unconsciously provoke the staff into holding him to get the nice, warm, cuddly time afterwards. To break the pattern you need to keep giving, giving, giving to this type of child. Give to him before he starts to demand attention by negative behaviour. If a child like this is being quiet for a while, don't breathe a sigh of relief and think, thank goodness, I don't have to worry about him for a while. Let him know that you are interested in him and in what he is doing so that he comes to realize that he doesn't have to be disruptive to get noticed.

For example, in one of the staff seminars in the Newmarket region I was told of a boy who was being held almost every day when he came home from school. The situation had reached the point where as soon as the staff in that house heard the car turning into the driveway they turned off the stove, moved the pots to the back and braced themselves for trouble. Staff really need to watch this kind of thing because children pick up unconscious messages coming from adults and if you expect a kid to screw up he will. I suggested to these staff that they might go out to meet the car with cookies in hand, and perhaps play a game with this child in the yard, then when he comes into the house give him a glass of juice, so that he receives the attention he craves without having to get into the kind of behaviour that provokes a holding.

With older children, especially those who have been around for a while, you can often talk to them and ask them how you can make things different for them so that they won't need to be held. Children are eager to find better ways of handling themselves and their anger and they often have valid suggestions. If not, suggest some alternatives yourself.

Sometimes a child loses control because a staff moves in too close; he may find it easier" to yell at you without losing control if you stay on the other side of the room. I remember working with a big teenage girl, so strong it was almost impossible to hold her safely. We made an arrangement whereby when she was really mad about something we would sit at opposite ends of the dining room table while she told me about it. We might both be yelling at the tops of our voices at times but the table between us helped her maintain her controls. (Although this girl left the treatment program many years ago, I still hear from her regularly. She is doing very well and is now running a small group home in the State of Michigan.)

Sometimes the arrangement you make with a child works for a while and then breaks down. Don't give up or let the child give up when that happens. Say, well, it didn't work today but we'll try it again next time; or ask the child if he can think of anything that would make things easier for him. Don't become discouraged or let the child become discouraged; it takes time and we all have our bad days.

The staff must control the holding, not the child, and this includes the timing. We always try to avoid holdings during life essential routine activities. That doesn't mean that if Johnny throws a rang at wake-up you say, I'm sorry I can't deal with you right now because it's wake-up time. If a child has to be held he has to be held, but if you know your children well enough you can sense when tension is building up to the point where they may have to be held and you can trigger off the holding at a more convenient time. We try to keep the daily routines conflict free so that the child gets up, gets fed, goes to school and goes to bed at a reasonable hour.

With some children you can be very direct and say, we like suppertime to be a nice time for everyone when we enjoy good food and one another's company, so you can get mad at me at 4.30 p.m. and you can get mad at me at 5.30 p.m. but

don't mess up supper. If you have a child who is disruptive persistently at supper time, you may need to look at what suppertime meant to this child before he came to us. It may have been the time when mom told dad all the bad things that Johnny had done that day, so for Johnny supper-time was confrontation time. Be sensitive to the anxieties of the child who has had this kind of experience. Children soon become aware that at Browndale supper is an enjoyable time for everyone and as they come to feel they deserve a nice mealtime they stop the disruptive behaviour. Occasionally it is a staff who always manages to be away from the table — dealing with a child or making a phone call — and he may need to think about, or talk to someone about, why he finds it so hard to sit at the table and enjoy a nice mealtime.

Be aware of patterns of behaviour because they can be revealing. Some children are always getting held when their favourite staff has a day off, or half an hour before he is going off duty, or the day before a visit home. There are better ways than holding for helping a child deal with these anxieties.

However, if a child has lost his self-control and is in danger of hurting himself or anyone else, or is damaging property, being physically held by people who care for him is a better method of restraint than being locked up in a room by himself, put in a straitjacket, or drugged into insensibility, methods used by many hospitals and institutions for children.

The holding technique was first developed by John Brown as a method of maintaining safety when boys that he and Dr. Friz Redl were working with were taken on a camping trip. It is based on a natural pattern of control found in healthy, extended families in the community. When a small child has a tantrum, an adult will hold the child in his arms until he quietens down. Emotionally disturbed children may be 10, 14 or 16 according to their chronological age, but in their emotional immaturity they are similar to much younger children. By physically holding the child who has lost control, the adult is saying, I am in charge, I will keep you safe. This is a responsibility an adult must take for young children and for older children who have not yet developed their own controls.

In closing, I would like to re-emphasize the main points that I have made in this article. Holding is a non-punitive method of restraining a child who has temporarily lost his self-control. In the context of a relationship with staff who know and care for him, he is prevented from engaging in dangerous or destructive behaviour. Staff involved in a holding need to know how to move in quickly and hold a child safely. They should also be sensitive to the feelings of the child being held and aware of their own feelings and where their own controls are at. Finally, as I have emphasized throughout the article, holdings can often be avoided through the sensitive use of other approaches, some of which have been described in this article.