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Lakota construct focuses on child's strengths.

SPEARFISH CANYON, S.D.--Four direction points on a Lakota Sioux medicine wheel are shaping behavioral assessments of children, with clinicians sitting elbow-to-elbow with educators and youth workers as they learn to assess development according to resiliency, strengths, and each child's private logic.

Traditional assessments may focus primarily on physical milestones or discrete behavioral cues, but the Developmental Audit stresses four values: Connections, Mastery, Independence, and Generosity, deemed by the Lakota people to be the naturally balanced ideals necessary to become a fully formed human being.

The approach tends to highlight strengths at the outset and illuminates areas in which the environment may or may not be cultivating the child's developmental needs, said Dr. Larry Brendtro, a psychologist who directed Starr Commonwealth, the nonprofit children's group, before cofounding Reclaiming Youth International, a nonprofit agency devoted to strength-based approaches to youth. "In many cultures, values are closely matched to basic human needs," he said during a 3-day workshop on the Lakota-based Circle of Courage.

Throughout history, societies often constructed "back-up systems" to meet these needs, with elders and community members ensuring a sense of belonging or fostering mastery, for example. Today, if families falter, these needs might be met by schools or communities. If not, the child's circle will appear broken.

What Dr. Brendtro calls "Elder Deficit Disorder" might deprive young children of the nurturing oversight of many adults present in their lives who would encourage independence, mastery, and generosity of spirit. School failure, social deficits, poor self-esteem--even gang membership--might be seen as the symptoms of underlying unmet needs within the Circle that a physician might be able to identify, even in a short visit, he said.

Besides obvious gaps in connection, modern American culture often favors "mastery" over a quality such as "generosity," said Martin Brokenleg, Ph.D., a psychologist and faculty member emeritus at the Vancouver School of Theology in British Columbia. In tightly controlled homes, there may be almost no attention to "independence."

The point is to determine whether children's circumstances have offered the opportunity to develop each of the ideals, and, if so, whether they have been able to take advantages of these offerings. The Developmental Audit can be brief, constituting just a few moments of a routine office visit, or expanded to understand a child within the context of behavioral problems and/or referrals from school.

Connections (representing the "Belonging" value) are often jotted within bubbles on a brightly colored intake sheet, as the child notes special relationships within the family, peer group, school, and community.

Mastery is determined by traditional measures, such as the report card or physical capabilities, but also draws from the child's own description of his or her passions and accomplishments, both in and out of school. Often, these remarks offer insight into special interests that may figure prominently into the "goals for growth," or action plan.

Independence is a marker of maturity and self-control. The ecological framework is an important consideration: Do the family, community, and school offer increasing flexibility to the child, nurturing values of self-confidence, good judgment, and appropriate risk taking? Or is the environment so rigid the child finds distorted ways to assert independence through rebelliousness and power struggles?

Finally, the child is asked about opportunities for generosity as a way to catalogue evidence of empathy, loyalty, sharing, and altruism, the highest value in the Lakota culture.

Dr. Paula Duncan, professor of pediatrics at the University of Vermont, Burlington, and one of the editors of the new Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, Third Edition (American Academy of Pediatrics), has attended several Reclaiming Youth International workshops and has noted the "nice fit" of their underlying concepts with pediatric practice.

The four core values all appear in some fashion in the new Bright Futures guidelines that provide structure to well-child assessments for children ages 8 and up as recommended by the American Academy of Pediatrics, American Academy of Family Physicians, and 18 other organizations devoted to the healthy development of infants, children, and teens.

If children possess a strong sense of belonging, mastery, independence, and generosity, research shows that they are also more likely to do well on six key health behavior criteria shown by the Centers for Disease Control and Prevention to be associated with mortality and morbidity in youth, said Dr. Duncan.

These behaviors include physical activity, nutrition, sexual behavior, substance abuse, safety, and emotional well-being.

A child with warm connections and a sturdy sense of independence will be less likely to use drugs or to join a gang, for example. A teenager who prizes a growing sense of mastery in a team sport has a sense of belonging; a preteen who has learned to appreciate and respond to the needs of others (generosity) is developing a healthy perspective that can serve as an anchor in the face of peer pressure.

"[Many providers] are assessing mastery and belonging all the time in their practices. They've never heard of looking at the others, but when they start asking about these things, they start seeing their potential in identifying protective factors and strengths," she said during an interview. "They really capture the things children are trying to accomplish."

* Watch a video interview with Dr. Brendtro at

RELATED ARTICLE: Approach Targeting Healthy Behaviors at Work in Vermont

Armed with stickers, chart check-off forms, and a bright picture of the Circle of Courage, Dr. Paula Duncan and her associates are teaching pediatricians, family physicians, and their staff throughout Vermont how to assess preteens and adolescents for the riskiest health challenges they face.

They have visited 60 practices in their quest to introduce office-based interventions for older children to help them avoid diverse health threats such as obesity, unsafe risk-taking behavior, substance abuse, or emotional crises.

Supported by a coalition of health plans, Vermont Medicaid, the American Academy of Pediatrics, and the American Academy of Family Physicians, the effort links quality improvement efforts to youth, risk behaviors that contribute most to morbidity and mortality.

Instead of simply listing the behaviors and holding practices accountable for prevention, the Vermont approach offers clinicians tools to use in assessment and the fostering of healthy behaviors. To begin, each practice chooses one healthy behavior to target, with the promise that they will incorporate preventive strategies into each routine visit.

"We show how to screen every patient for their protective factors and strengths, using the Circle of Courage as a guide," said Dr. Duncan, professor of pediatrics at the University of Vermont, Burlington, and Youth Initiative Director of the Vermont Child Health Improvement Program.

Drawn from Lakota Sioux teachings, the Circle of Courage developed by Reclaiming Youth International of Lennox, S.D., embodies four values for assessing development: belonging, mastery, independence, and generosity. They form building blocks for development in older children, fostering a healthy body image, a sense of educational purpose, nutritional and exercise goals, supportive social connections, independent decision-making skills, and the satisfaction that comes from contributing to the community.

Dr. Duncan demonstrates for health professionals a guided interview that elicits information from children about how their lives reflect each section of the circle.

"I can't help notice you've got a lot of this," she might say, pointing to mastery and talking about a teen's grades in school or artistic accomplishments. "It seems to me you've got a lot of strengths."

With regard to less successful areas--having sex without protection, for example--she might ask what steps the teen might take to increase her ability to be independent and take responsibility for her future.

"There is a lot of shared decision making here," she said. "You need to figure out what kids should say 'yes' to, and strengthen that."

In practice, these guided interviews take only a few moments and serve many purposes: building rapport, demonstrating respect, and motivating change by getting patients to begin seeing their behavior in a different light. "My job is to make this do-able in a short time. A pediatrician is going to have to put this whole thing together in 15 minutes with the patient," she said. "We're giving them a structural framework and some words to use."

So far, the response from medical practices has been encouraging, according to Dr. Duncan.

Although results are preliminary, chart audits suggest clinicians are having more discussions with their school-aged patients about their developmental strengths and ways to shore up the areas that need improvement.

* Watch a video interview with Dr. Duncan at
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Author:Bates, Betsy
Publication:Clinical Psychiatry News
Article Type:Report
Date:Mar 1, 2010
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