Learning to Work with Most Vulnerable Children and their

Families

A Project of the Social Work HIV/AIDS Partnership for Orphans and Vulnerable

Children in Tanzania

Day 6

Support and Behavior Change for Vulnerable Children and their

Families

Social Work Process for Working with Orphans and Vulnerable Children

Affected by HIV

1. Identifying Vulnerable Children and their Families

2. Engaging Vulnerable Children and Families3. Assessing their Strengths and Needs4. Developing a Plan of Services for Vulnerable

Children and their Families

Social Work Process for Working with Orphans and Vulnerable Children Affected by

HIV

5. Implementing the Plan of Services• Identifying and Referral to Other Resources • Providing direct services: problem solving,

support and coordination• Empowering and supporting caregivers• Addressing HIV related prevention and care

concerns6. Evaluating Progress, Revising Service Plan and

Following Up Through Ongoing Case Management, Family Support And Advocacy

ObjectivesAt the end of this day, Para Social Workers will be able

to:

• Explain the basis of behavior change and the stages of change model

• Explain the concept of risk reduction and how to support risk reduction decisions

• Demonstrate skills in family-based problem solving and risk reduction for vulnerable children, families and caregivers

• Explain the process of grief and loss in the context of vulnerable children and families

Planning for Behavior Change

Para Social Worker as a Change Agent Supporting Vulnerable Children and their

Families

Planned Behavior ChangePlanned behavior change has three aspects:

• Adapting: some change based on the environment

• Altering: a complete change based on internal motivation

• Modifying: partially changing the degree of the target behavior for a variety of circumstances

Planned Change

• People change in response to their situation (environment) to satisfy needs and their goals

• Active, dynamic process where people interact with their environment as an ecosystem in which each shape the other

• People may change their environments to fit their physical and psychological needs

Change is Affected By….

• Developmental growth, maturity • Changes in situation

• Family loss, • Loss of income • External forces affecting established patterns of

behavior• Change in family responsibilities

• Individual decision to change a behavior they see as harmful and/or unacceptable • Example: Unprotected sexual behavior may lead to health

problems• Example: Traditional practice (e.g. female genital cutting)

has become known in the community as unsafe

Change is Affected By….

• Other factors (within the person or the situation)• Peer pressure• Increased knowledge of the effects of harmful

behavior • Family or community pressure (either positive or

negative)• Symptoms of illness and/or physical distress• Positive or negative social pressure from all

levels of society• Policy-related pressure

Risk Reduction

• Risk reduction is a model of behavior change that can be helpful in understanding how behaviors change and how para social workers can be helpful in that process. It focus on modifying the risk instead of modifying the action/behavior

• Risk Reduction strategies reduce harm while giving the client the space, time and positive feedback required for permanent behavior change

• Risk Reduction may provide useful ways to change over time by reducing negative behaviors or increasing positive ones.

What are some examples of risk reduction behavior s (negative or

positive)

Brainstorm

What are some examples of risk reduction behaviors

(negative or positive)?

• Reducing the number of sexual partners• Increasing condom usage• Decreasing the amount of substance

consumed

Role of the Para Social Worker in Planned Behavior Change

• Planned change is an approach to problem solving based on – Problem assessment– Knowledge of the individual’s readiness for

change– Change focused intervention

• Para Social Worker functions as a change agent with the child/family and jointly plans with them for change

• Planned change has a specific purpose and increases the likelihood of predictable outcomes as a result of the change efforts (Hefferman, et al., 1988:10)

Risk Reduction and Behavior Change

• Risk reduction or harm reduction approaches assume that:• Behavior change is a process that occurs over time rather

than a single event• Risk Reduction involves many factors, including

psychosocial relationships as well as other social and environmental factors

• Risk reduction strategies must be broken into small enough steps for the person to do successfully

Stages of Change

Circle of Change

• The model “circle of change” describes the stages of change each person goes through on the journey to changing behavior.

• This “stage of change” model was developed by Prochaska and Diclementi (1982) who differentiated six stages in the change process.

Circle of Change

• This model is not presented to suggest that change is simple or easy, but rather to emphasize that change is complex and involves a process.

• Para Social Workers can assess where a person is in the change process and choose interventions appropriate to that stage.

• This helps Para Social Workers “begin where the person is”

The Stages of Change

1. No change planned (Pre-contemplation)

2. Thinking about change (Contemplation)

3. Deciding to change (Decision)

4. Changing behavior (Action)

5. Continuing the change (Maintenance)

6. Relapse returning to the harmful behavior (Relapse)

Circle of Change

Continuing

No

Cha

nge

Thinking

Relapse

Deciding

Cha

ngin

g

No Change Stage

Person has no desire to change, or is not aware of the problem or is ignoring it, or is in denial

• Role of the Para Social Worker• Provide information and feedback to raise

awareness of the problem and the possibility of change• Information should not be judgmental

• Involve family, social and community forces to help introduce the idea of behavior change

• Provide assurances that positive support for change will occur

Thinking StageThinking about change, feeling somewhatConcerned about the behavior, but not havingyet made commitment to change

• May be a lengthy process requiring the person to move from accepting the problem, to accepting some responsibility, to feeling a need to do something about the problem

• Considers change, but also may be threatened by it and thus may reject it

• Role of the Para Social Worker• Help the person tip the balance in favor of

change• Help the person see the benefits of changing

and the consequences of not changing

Deciding Stage

• Deciding to do something about the problem. Making a decision to make a change but has not yet put the decision into practice

• Role of the Para Social Worker• Help the person find a change strategy that is:

• Timely• Realistic• Achievable• Acceptable• Feasible• Appropriate• Effective

Changing Stage Taking action to make the change

• Role of the Para Social Worker• Provide continuous, ongoing support• Advocate with family and community to avoid

blame and to support change• Help accomplish the steps for change

Continuing StageContinuing or maintaining the new behavior

Role of the Para Social Worker• Help person continue to engage in the new

behavior • Provide tools such as reminders, calendars,

rewards to sustain positive change• Identify possibility of returning to old behavior

(relapse)• Help person identify and use strategies to

prevent relapse• Help the person to acknowledge the success of

behavior change maintenance

Relapse Stage

Goes back to the original behavior

• Can lead a renewed decision to further work on the problem

• Relapse can result in going back to the old behavior which will put the person back at the beginning of the circle of change

Relapse Stage • The role of the Para Social Worker

• Assure the child/family that change is still possible and that relapse is not uncommon

• Assure the child/family member that our support will continue even if behavior changes

• Avoid blame, judgment and other negative responses

• Assure the child/family that positive change can endure

• Identify the conditions that led to relapse• Help the child/family to understand how to change

those conditions to sustain positive behavior

The Role of Para Social Workers:

Problem Solving for Behavior Change

and Risk Reduction

Helping Families to Solve Problems

To help families solve problems, Para Social Workers always working as:

• Helpers • Links to services in the community (Discussed

in Day 5)• Family and community advocates

Who are the Community Resources Who Can Help Solve Problems?

• Para Social Work Supervisors • Medical doctors, Nurses, Teachers• Experienced Counselors in the Community

• Religious Leaders• Skilled situational counselors

• Experienced school counselors• Experienced mental health or addiction

specialists• Social Welfare Officers

Para Social Worker as an Agent for Problem Solving

• Help the family get basic needs (food, clothing, shelter)

• Help the caregiver or child to accept support for problem solving

• Help other family members to support problem solving activities

• Plan for linkage services between the child and family and the referral source if necessary (discussed in Day 5)

• Coordinate with other providers so that the linkage can be efficient, effective and timely

The Role of a Para Social Worker: Problem Solving for Change

Focuses on the process of change, which requires:

• Developing and maintaining rapport with the child/family within the context of change

• Identifying and exploring how to effect change• Identifying and exploring the willingness to change

and barriers to change• Exploring the support required for long term

behavior change• Selecting an option/solution and making a plan for

behavior change

Overview: The Problem Solving Model

1.Building the Relationship

2. Exploring the Problem

3. Understanding the Problem

4. Planning for Action and Evaluating Results

The Problem Solving Model

1. Building the relationship and communicating, requires nonjudgmental communication skills

• Tone of voice• Attending behavior • Questioning• Paraphrasing• Reflecting feelings• Summarizing• Non-judgmental

The Problem Solving Model

2. Exploring the Problem. Make the problem specific

• What is the problem? • When did it start?• How much of a problem is it?

The Problem Solving Model

3. Understanding the Problem• Label the feelings – sad, happy, angry• Notice nonverbal messages/feelings and

reflect them back• Acknowledge and affirm conflicting or

ambivalent feelings • Tie the feelings to the facts or to the problem

The Problem Solving Model

4. Planning for Action and Evaluating the Results

What are possible activities?

Brainstorm

The Problem Solving Model

4. Planning for Action and Evaluating the Results• Plan together with the child or caregiver• Explore past attempts to solve the problem• Explore how to solve the problem now• Share your ideas about possible solutions• Follow up on the plan of action

The Problem Solving Model of Counseling

Select an option/solution and make a plan

• Help the child or family member choose a realistic solution

• Which solution might work best? Why• Which strategy is feasible for the child or

family?• How and when would the person be able to

solve the problem (specific action plan)?

Para Social Worker’s Role: Following up on the Plan

• Help to establish a family and community support network to support the problem solving plan of action

• Decide who will do what, when, and where• Make referrals as appropriate• Follow-up to see if the plan was followed

Life of a Child III: Grief and Loss

Overview: Grief and Loss in Children

• All children experience grief and loss when separated from their parent(s) whether by illness, death, or abandonment.

• Like other aspects of human development, grief and loss depends on gender and developmental stage among other factors.

Overview: Grief and Loss in Children

• Feelings about grief and loss may cause many behaviors that indicate grief and loss, for instance: • Anger• Sadness• Hyperactivity• Becoming withdrawn

• These feelings are appropriate but may produce behavior s that are harmful to the child, others, or property

The Grief Process• Feelings about grief and loss may cause

many behaviors that indicate grief and loss, for instance: • Anger• Sadness• Hyperactivity• Becoming withdrawn

Grief Process

• Grief, like behavior change, is a process that may assume a circular form. People experiencing grief and loss may revert to prior stages depending upon other circumstances. An unrelated event or trauma may evoke a renewed grief reaction for the earlier loss.

• What do you think are stages in the process of grieving?

Brainstorm

Stages of Grieving

• Shock/Denial• Anger• Bargaining• Sadness and Depression• Acceptance

Note: • Everyone may grieve differently. • May not go through stages in order and may

move back and forth between the stages.

Developmental Grieving

• We may grieve even after we believe we have achieved acceptance

• Children revisit losses at each stage of development

• Children may seem to forget the loss for a while, then suddenly become very sad or angry

• Sometimes children seem to have reached acceptance but have simply “bottled up” their feelings. These strong feelings may erupt at a later time

• Multiple losses trigger strong, but unresolved emotions from previous losses

Effects of Developmental Grieving

• Children who are separated from their parents due to illness, death, or other cause will be grieving

• The pain of separation and loss is a type of trauma• Children can become stuck at one level, or even go

back to an earlier level of development

Impact of Developmental Grieving

• Children who are separated from parents may appear angry, depressed, or hostile

• When we see a child who angry this may reflect their experiencing loss and pain (“Whenever you see anger, look for the pain”

• Other children may appear charming and carefree. This is a way of hiding the pain of loss

Events and Contexts that Trigger Grieving

• Anniversaries• Birthdays• Weddings• Holidays• Special songs, foods, etc.• Places associated with the loss• People who have the same name or look like the

missed person

Factors that Affect Ability to Grieve

• Nature of the loss • Health and self-esteem• Age at time of each loss

• Children who don’t understand the concept of death may not be able to grieve appropriately and may then experience delayed grief

• Degree of attachment to lost person• The intrinsic vulnerability of the person

experiencing the loss

Factors that Affect Ability to Grieve

• Circumstances causing loss• Is there a difference in grieving between a

sudden loss and a loss experienced after a long illness?

• Number of previous separations• Support provided during the process of the loss

(before, during or after)• Help given prior to, during, and after the loss

Challenges of Helping for the Para Social Worker

• Helping children with loss may be challenging because:• Separation and loss are painful experiences• Developmental grieving may be frustrating• It is uncomfortable to be with children who are

angry and sad• Other people’s grief reminds us of our own

painful experiences• Working with children and families around loss

requires patience. Dealing with painful losses takes a long time – even a lifetime

HOW TO HELP THE CHILD

• Shift child’s focus from feeling worthless to strengths and hope

• Provide information• Children need information about

themselves, their family, their situation, decisions being made about them.

• Having information about their lives helps children feel secure and safe.

HOW TO HELP THE CHILD, continued

• Assure children are connected in terms of personal relationships and within greater environment

• Minimize the losses children experience by maintaining the child’s connections to siblings, extended family, and other people of importance to the child.

• Work to develop attachment relationships with caregivers.

• Secure financial support for the child.

HOW TO HELP THE CHILD, continued

• Group Membership

• Involve the child in age appropriate groups: the family, groups focusing on issues of interest to the child, etc.

• Meaningful Roles

• Help the child perform significant roles in the family, at school, within peer groups, etc.

HOW TO HELP THE CHILD, continued

• Help identify experiences that provide a source of Joy• Celebrate the child’s achievements.• Include the child in family and cultural holidays

and celebrations.• Teach Constructive Values and Attitudes

• Involve the child in religious or other activities that teach a system of values and morals to guide the child’s behavior .

• Consistently model the values and morals you wish to impart to the child

HOW TO HELP THE CHILD, continued

Personal History• Due to their young age, orphans and vulnerable

children often forget the details of significant events in their lives. They may develop a confused sense of their own history.

• Preserve for the child information about events in their own lives such as: where they were born, places they have lived, people they have lived with, schools they have attended, people who have been significant in their lives. Memory books or other scrapbooks or boxes can be helpful in this.

HOW TO HELP THE CHILD, continued

• Ensure child is connected to a place • Most people have an emotional attachment to

a place they identify as “home”. Children who have moved often or lived on the street may not have a sense of where “home” is.

• Stabilize the child’s living situation and minimize moves to help the child develop a sense of stability and belonging.

HOW TO HELP CAREGIVERS

Para-social workers can have the most positive impact on a child by strengthening the capacity of parents and other caregivers to provide nurture and appropriate structure.

Help caregivers to understand that:• Understand that as child grows and develops, all the

steps in the grieving process may need to be expressed over and over again

• Grieving children may be confused about parent-child relationships.

HOW TO HELP CAREGIVERS, continued

• Helping the child takes persistence, skill, patience

• Helping the child requires continuing help over time• Child’s needs and feelings are important• Child is safe and is going to be cared for• Child’s needs can be expressed and met• Parents can be consistent and trusted

SummaryLarge Group Brainstorm: What are the three most important points in the topics covered today?

• Behavior Change• Risk Reduction• Stages of Change• Problem Solving Skills• Grief and Loss

– Children– Caregivers

References

• Pasztor,E., Blome, W., Cavin, B., Langan, J., Leighton, M., McFadden, E., Olea, M., Petras, D., Polowy, M., Ryan, P.,Sweency-Springwater, J., & Wynne, S. (I 993).

• FosterPRIDE/AdoptPRIDE: Preparation and assessment program for foster and adoptive families. Washington, DC: CWLA.

Day 6 Group Skills Workshopbehavior Change and Problem Solving

Skills

• Appointed a recorder to report for RECAP tomorrow• Discuss

• Questions from today’s session regarding using problem solving skills and behavior change skills

• What are some strategies to work with the child, family and community to help change behavior in your group case?

• Work in mini-groups • Assign roles as para social worker, child or

family/neighbors • Role play a para social work session to help address

some specific problems or behavior change• Discuss with whole group what did you learn?