The following article was published in a Best Practices journal in the spring of 2000.
The Nurtured Heart Approach has been practiced at Tucson's Center for the Difficult Child (CDC) between 1994 and 2001. It is a strategic family systems approach designed to turn the challenging child around to a new pattern of success. The approach has also been found to produce substantial success in helping the average child flourish at higher-than-expected levels of functioning.
The approach is now used in hundreds of classrooms nationally, and its strategies have been adopted with substantial success as the school-wide discipline plan in several Tucson schools.
The Nurtured Heart Approach teaches significant adults how to strongly energize the child's experiences of success while not accidentally energizing his or her experiences of failure. Most approaches, because they were designed for the average child, get stretched beyond their capacity when applied to challenging children. Traditional approaches for parenting and teaching can easily backfire with challenging children: they inadvertently reward children by providing more energy, involvement and animation when things are going wrong. Challenging children wind up being very confused because they perceive a high level of incentive for pushing the limits and for negative behaviors and little incentive to make successful choices. Often, the harder adults try applying these normal methods, the worse the situation becomes, despite the best of intentions.
Since The Nurtured Heart Approach was first introduced at CDC in 1994, a number of studies have been undertaken and several positive outcomes have emerged.
Tolson Elementary School in Tucson Arizona, a Title I school of over 500 children (80% free or reduced lunch) has shown remarkable progress since beginning a school-wide Nurtured heart Approach intervention in 1999. Prior to that many children were referred for ADHD assessments and were put on medications. They had eight times the normal number of school suspensions per year as other schools in the district and teacher attrition was well over 50% per year. Since that time there has only been one child suspended, no children at all diagnosed as ADHD and no new children on medications. Teacher attrition has dropped to less than 5% and special education utilization has dropped from 15% to 5%. Best of all, the school has gone from the worst in district as measured by standardized test scores to having dramatic and continuing positive progress. This data is in keeping with other informal observations noted when this approach has been applied in other school-wide applications.
Many HeadStart programs around the county use The Nurtured Heart Approach. The city of Tucson adopted the approach in the year 1999 and has used it successfully every since. The data they have collected for the 3,000 underprivileged children they serve each year confirms that in this time period they too have not needed to send a child for a diagnostic assessment or medication services at all. They use the approach class-wide and in addition to feeling that the approach helps all the children to flourish it has helped them to help the at-risk children to do well within the classroom setting without needing outside services.
Both Tolson Elementary and Tucson HeadStart report a strong increase in their ability to positively impact the parent communities they serve.
The most recently published findings are from the 1999 "Year in Review" study conducted by Pima County Juvenile Court in relation to the Pre-Adolescent Diversion Project (PADP) of Tucson's Child and Family Resources. The project's parenting component and several other aspects of the program are based on The Nurtured Heart Approach. The project is a 16-hour workshop series over 4 weeks for first offending youth and their families.
According to Pima County Juvenile Court researchers, first offenders referred to other Juvenile Court programs have shown a 32% rate of recidivism, whereas the rate of re-offense for those youth who have completed PADP with their families is only 18%. This represents a 45% rate of improvement over other diversionary programs. Typically, youth who re-offend do so at escalating rates of intensity, committing bigger crimes and more often. The graduates of PADP who did re-offend committed lesser offenses. The statistical significance of the 18% rate of recidivism is .00001. This occurrence could not have happened by chance alone. Therefore, the strategies and approach of the Pre-Adolescent Diversion Project have been shown to produce noticeable improvement.
Another indicator of The Nurtured Heart Approach's effectiveness may be related to informal research regarding the use of medications among CDC clients.
Although many children referred to CDC are already on medication, CDC has scrutinized the records of children who are referred to the agency with no prior evaluation and therefore are not taking medications at the time of intake.
Upon close examination of the initial assessments of those already on medications and those not on medications, no difference is discernible. Those who are referred who are not on medications typically have very much the same symptoms and levels of severity as those who are already on medications at the time of intake. Most frequently those symptoms match the profiles of Attention Deficit/Hyperactivity Disorder (ADHD) and Oppositional-Defiant Disorder, with problems of aggression, compliance, impulsivity, distractibility, and a preponderance of school related issues.
National statistics show that of all children going to a primary care physician or a child psychiatrist for an initial assessment with these kinds of symptoms, 75% are prescribed medications at the time of that evaluation. It can therefore be assumed, given the kinds of symptoms and the level of severity of the children referred to CDC, that approximately 75% of these children would be put on medications if CDC's very first step were referral to a physician for an evaluation.
During a 10-month period in 1998, CDC worked with 211 children. Of these, 51 were already on medications prior to referral to CDC. Of the 160 children who were not already on medications, only eight were subsequently referred for psychiatric evaluations and only four were actually prescribed medications subsequent to the evaluation. This represents less than a 3% rate of utilization of medications. Perhaps just as interesting is that nine of the 51 on medications were successfully transitioned off medications during this time frame.
A separate on-going study conducted collaboratively by the Community Partnership for Southern Arizona (CPSA) research department since late 1996 involves pre- and post-treatment administration of the Connor's Parent Rating Scale with all CDC clients. Preliminary assessment of the data indicates excellent results in terms of efficacy of treatment. All scales of the Connors show improvement at the .01 level of significance and five of the six scales show improvements beyond four standard deviations. The study further confirms that, in general, the presenting symptoms of CDC clients at intake show a high degree of severity while the outcomes show children well within the mid-range of normative behaviors. Further analysis will be forthcoming.
Utilization of high-level services:
Considering the consistently high severity of CDC clients at intake, a fairly remarkable outcome has emerged over the years in relation to the number of CDC children who eventually needed high level and costly interventions such as out-of-home placements. Since 1994, only 8 children have required higher levels of intervention. This is despite the fact that many of the children referred to CDC over the years had one or more mental health related hospitalizations prior to referral to CDC.
The Nurtured Heart Approach also has been called upon numerous times to help transition children from high-level interventions to normal family life and regular levels of treatment. The related preventive request--to take on a child headed for a high-level intervention as a way of re-stabilizing the child--is also a routine facet of the capacities of this approach.
In a study of 808 of CDC cases from November 1994 through October 1998, only 28 children needed to have their cases re-opened and, in most of these instances, subsequent treatment was very brief and successful. Most of these families needed only a little inspiration or clarification on how to get back on track with the approach. The rate of re-utilization is less than 3.5%.
Many consumers do not qualify for the public mental health system and find the cost of on-going private treatment prohibitive. The Nurtured Heart Approach, typically taught for 8-12 total hours over a four-week period, is very well-suited to multi-family group scenarios, thus allowing families without insurance benefits to have an alternative form of affordable treatment.
In 1996, Dr. Shirli Ward researched The Nurtured Heart Approach for her doctoral dissertation. Comparison of a Nurtured Heart Approach large group format (over 30 parents in one group training) showed levels of success similar to that produced by therapeutic work with individual families. Dr. Ward pointed out that other prominent parent training programs were limited in size to a maximum of eight families, making The Nurtured Heart Approach considerably more time and cost effective.
The study also found that it was not necessary for both parents to participate in the training to achieve beneficial results. In one component of the study, only mothers were involved in the training and their children were not directly involved in the treatment. The mothers were able to become, in effect, the "therapists." The results reflected a high degree of satisfaction with the program in terms of improvements in family life and the progress their children made.
Dr. Ward further assessed the effect of the approach on child and parent functioning using the Devereaux Scale of Mental Disorders along with the Parent Stress Index, the Parenting Sense of Competence Scale, the Beck Depression Inventory, and the Forehand Satisfaction Survey.
Dr. Ward found that, relative to subjects in the comparison group, those involved in The Nurtured Heart Approach parent-training model demonstrated significant changes in functioning following treatment. Mothers reported significant (.01) improvements in their child's behavior related to the following: conduct, anxiety, communication, acute problems, and overall severity. In addition, in terms of their own well-being, mothers reported fewer depressive symptoms, decreased stress levels and increased parenting effectiveness and satisfaction following treatment.
These results were found to be consistent across the researched diagnostic categories of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder and Depressive Disorder as well as for children for whom treatment was sought for general noncompliance and Adjustment Disorder.
In 1994, Dr. Lorence Miller, also using the Devereaux Scale of Mental Disorders, found that a sample population of children in treatment at CDC had higher levels of severity at entry into treatment than the comparison groups of selected specific diagnoses used in the Devereaux groups own studies of criterion-related validity. The CDC sample population had more severe problems in all areas but attention. Dr. Miller's post-test results for both The Nurtured Heart Approach family treatment and large multi-family group treatment modalities were shown to have extremely significant effects toward normalized behaviors.
Perhaps one last measure of The Nurtured Heart Approach could be viewed in relation to the training of professionals. The approach is so readily transferred to other professional that they become fully competent in a relatively short period of time.
CDC accepted its first two interns, both Masters Degree students in the University of Phoenix Marriage and Family Program, in 1999. Within two months, both were so effective with families in treatment that they were comparable to senior therapists in both the results they produced and their own perceived level of competency. This year, five more interns have applied to CDC training program and are following suit in their level of confidence. CDC attributes a great deal of the success of the training to the inherent power of the model: The Nurtured Heart Approach.
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