“The Jigsaw Puzzle Child” By Eileen Mayers Pasztor, DSW Every adult who interacts with children in foster care must understand average, expectable, or “normal” child development principles, and the often devastating impact of neglect and physical and sexual abuse on child well-being. As a foster care caseworker who grew up to become a foster and adoptive parent, here are two stories about child development that demonstrate what happens when caseworkers don’t have grounding in child development, and offers a tool that helps look at child development from a more realistic perspective. My decision to be a child welfare worker was not a career calling. I sought any job where a college diploma was required, and the county welfare department (as social services was called a long time ago) was seeking college graduates. With the qualifications of only a bachelor’s degree in history and a driver’s license, I was hired as a foster care caseworker. I didn’t even know what foster care was because I was fortunate to grow up in a family with nurturing parents. On my second day at work, I was sent to see a foster mother who had been fostering for more years than I was old. We had a disagreement about the age of a child in her care. According to the case record, the child was about one year of age. The foster mother said the child was three years old. I did see the child, but I didn’t stay long. When I returned to the agency, I told my supervisor, who recently earned a masters in social work, about what happened. My supervisor asked me what the child was doing, as a way to determine who was correct: the case record or the foster mother. I told my supervisor that the child was riding her tricycle most of the time. Everyone but myself was astonished that I didn’t know a one-year-old couldn’t ride a tricycle... I didn’t learn that as a history major. Years later, after I gained some experience in child development and of course much more, I returned to the agency and ran into that foster mother. She told me that I was the dumbest case worker she had ever met. Think of the mistakes that are made when basic information such as child development is not known. Many years later, after having the privilege of working with literally thousands of wonderful foster parents and child welfare professionals around the country, and becoming a foster parent, my husband and I decided to add to our family by adopting a child with special needs. He was chronologically ten years old, and had been in two residential facilities since the age of six. My parents were thrilled Reprinted with permission from The Foster Parenting Toolbox, edited by Kim Phagan-Hansel, published by EMK Press www.emkpress.com email@example.com 16 Mt. Bethel Road, #219 Warren, NJ 07059 732-469-7544 732-469-7861 fax A Benefit of Membership Foster Parenting Resources and Information from NFPA at the addition of who would be their only grandson. But it didn’t take long for them to be frustrated with his behaviors, least of which was his “excess energy” and inability to focus on any activity for more than a few minutes. Try as I might to prepare them that he was going to be “different” from other ten year olds, we were all struggling. So I invented the “jigsaw puzzle” activity to show them how he wasn’t really ten years old. The Jigsaw Puzzle Tool Children have eight parts to their development: their age in years; appearance age; IQ age; academic age (grade in school); emotional age; social age; whether they are an ethnic match with the family they are living with, and how many years of customs, values, and traditions they share; and their life experience age. Most people – like my parents – were expecting that a ten-year-old would look between 9 and 11 years of age, would be in the fifth grade, would be of average or above intelligence; would be white like us, and would share our family values and traditions. Children who have experienced the tragedy of abuse and neglect and sexual abuse have fragmented pieces. See the puzzle below – that’s the puzzle for a child born with the blessings of good genes and good environment. The next puzzle – that’s my son. He was 10 years old in years, but he looked eight (small for his age). He processed information like an eightyear-old according to his IQ test and, academically, he didn’t read or write when he came to us: not one word. So he was academically preschool age. Ten Year Old Good Genes Age in Good Environment Years: 10 IQ Age: 10 Appearance Age: 9-11 Years of shared customs, values, traditions 10 Emotional Age: 10 Social Age: 10 Life Experience Age: 10 Ethnic Match= yes Academic Age: 10 The Typical Ten Year Old Pg. 2 Jigsaw Puzzle Child by Eileen M. Pasztor, from the Foster Parenting Toolbox (EMK Press 2012) Regarding trust, why should any child who has been abused or neglected by adults trust any of us? We think of families as safe havens. Children coming into the foster care system typically see families as places where children get hurt. Mom neglects you when she is high; her boyfriend abuses you because you’re just a reminder that she had sex with someone else. Families can be scary places. This can be especially true if you’ve lived with many previous foster or even adoptive parents who started off by saying, “I love you,” and then called for your “removal” (like you were garbage or snow) when your behaviors acted out your normal feelings of fear and anger. Socially, after living in a residential setting with other challenged children, our son could do parallel play but not interactive play, which made him socially at the preschool age. We were an ethnic match, but we had zero years of shared customs, values, and traditions. He wanted to sleep with us because that was what he had been taught before he was sent away to residential; and he wanted to be sure we wouldn’t abandon him in the middle of the night. As another example, when our foster daughter came to live with us, she had the custom of sleeping with her shoes on her pillow. That’s because, where she used to live, she never knew who would try to molest her in the middle of the night; she used her shoes as a weapon or to run. To assess the “life experience” age, you look at the range from the youngest age to the oldest age of functioning. In my son’s situation, this would place his youngest age of functioning at his emotional age, which was “birth through two” – when basic trust is established. For most children who have been abused or neglected, typical attachments and trusting relationship are suspect. His oldest age of functioning I list as 18 plus years of age. This is because children who have been sexually abused have experienced activities that many people don’t know about until they at least go to R-rated movies or have had some of their own more “grown up” or intimate relationships. How Does This Work? In every child welfare class I teach, in every workshop I do, in every keynote I give, I demonstrate the “jigsaw puzzle child” activity. I usually do it with two pieces of flip chart paper. First I diagram the “typical” ten-year old. Then I diagram my son. And then I rip the pieces apart and throw them on the floor. This is because the child welfare and other “systems” don’t typically deal with children in foster care from a developmental perspective and in a unified way. The case record documents the date of birth or chronological age. Anyone who meets the child sees the appearance age. Schools interact with a different piece of the child, and so on. And if a foster parent has three children in their care, that’s actually 24 different ages and stages to protect and nurture. Pg. 3 Jigsaw Puzzle Child by Eileen M. Pasztor, from the Foster Parenting Toolbox (EMK Press 2012) Age in Years: 10 IQ Age: 8 Academic Age: preschool Ethnic Match= yes Appearance Age: 8 Years of shared customs, values, traditions 0 Emotional Age: B-2 Social Age: 4-5 Life Experience Age: B-2 to 18 Ten Year Old Genetic Challenges Abuse/Neglect My “Ten” Year Old Son Consider the risk factors for children whose pieces of their jigsaw puzzle do not fit together. What are the risks for a girl who is emotionally, socially, and cognitively 12 but looks like she’s 16? What are the risks for boys who look older than their abilities? And for young people of color, the risks are greater. Latino and African American males tend to get referred to juvenile corrections while Anglos are more likely to go to mental health facilities. What happens when these “jigsaw puzzle children” turn 18 years of age and the alarm on their independent living clock rings? Now, at the chronological age of 18 years, they are supposed to be “emancipated.” They “age out.” Listen to how awful those words sound, how unnatural they are. What do they sound like to a child? How can we expect safe and responsible behavior from someone who is 18 in years only, but socially, emotionally, academically, and cognitively much younger? And here’s another critical question: Who is responsible for putting all the “pieces” back together again? From now on, every time you think about a child in your care, your caseload, your classroom or even the courtroom, think of all the pieces of the puzzle. Put a jigsaw puzzle diagram in their records. Discuss the “jigsaw puzzle” pieces when getting ready to place children. It may be that the placing caseworker does not know what all the pieces are. It may be that some children have to live with foster parents for a while before their foster parents can determine what the “ages” are. Tell the judge. Remember, when you are considering sending children back to their parents, the parents have jigsaw puzzles pieces, too. It’s just their chronological ages are higher. Otherwise, their pieces look a lot like those of their children. How do we ensure child safety, well-being, and permanency when we send “jigsaw puzzle” children to live with “jigsaw puzzle” parents? Fast forward the clock: Our son is now in his thirties. He is a client of county mental health services. He cannot work; my husband and I help him with most of his tasks of daily living. He has a wonderful relationship with my 90-year-old parents, who accepted him many years ago, once they put the pieces of the puzzle together. I didn’t expect to be a mom to someone who is thirty-something in years, but emotionally and socially much more like a 14-year-old. However, I am humbled that, through his challenges, and those of my foster daughter, I was taught the lessons that enabled me to create and share these activities. I would have preferred, of course, that they had not had the experiences. But our adult “children” are safe, and we’re still a family. I hope this “jigsaw puzzle” tool will help facilitate safety, well-being, and permanency for the children in your care and in your caseloads, too. Adapted from: Child Welfare League of America. (2009). Foster PRIDE/Adopt Pride – Preservice Training for Foster and Adoptive Parents, Trainer’s Guide. Washington, DC: Child Welfare League of America, p. 243. Pasztor, E.M. & McCurdy, M. (2009). When work comes home and home goes to work – child welfare social workers as foster and adoptive parents. In E. Grise-Owens & K. Lay, (eds.), Reflections – narratives of professional helping. Special Issue: Inside Out – Reflections on Personal and Professional Intersections, Spring, Volume 15, #2, 95-105, p. 95; and p. 98. Pasztor, E.M., Polowy, M., Leighton, M., & Conte, R. (1991). The ultimate challenge: Foster parenting in the 1990s. Washington, DC: Child Welfare League of America. Eileen Mayers Pasztor, DSW, is experienced as a public agency caseworker and supervisor; as a curriculum developer and trainer; and as a foster and adoptive parent for children with special needs who, now as adults, continue to require her support. She teaches child welfare and social policy advocacy courses at the School of Social Work at California State University, Long Beach (CSULB), and edits the journal Reflections – Narratives of Professional Helping, and she continues to consult and train nationally
Terry Alves-Hunter, Foster Parent Advocate
Not in my womb, always in my heart
Learning & Emotional Assessment Program (LEAP) The Learning and Emotional Assessment Program (LEAP) at Massachusetts General Hospital assesses students and children ages 2 to 22 who have developmental difficulties and consults with their parents, teachers and care providers.
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Our experienced professional staff includes Child psychologists, Licensed clinical psychologists, Neuropsychologists, Certified school psychologists, clinical psychology interns and postgraduate fellows.
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Boston Medical Center
Dr. Augustyn is the Director of the Division of Developmental and Behavioral Pediatrics at Boston Medical Center (BMC) and is a Professor at Boston University School of Medicine. She went to medical school at Loyola Stritch School of Medicine, completed her pediatric residency at UCLA and her Developmental and Behavioral Pediatric Fellowship at Boston University-Boston City Hospital. Her clinical work at BMC primarily involves the evaluation of children with various developmental delays including autism,speech and language delays, global developmental delay, learning disabilities, ADHD to mention a few.
Her research work has varied across her career and includes work on the effects of both in utero cocaine exposure and violence on early childhood and parenting and recently she has been a leader in developing the Center for Family Navigation at BU, a national leader in promoting and developing the use of navigators to support families of children with developmental disabilities.
Dr. Augustyn is co-editor of The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care and the section co-editor for Developmental and Behavioral Pediatrics for the online journal UpToDate. She currently sits on the sub board of Developmental and Behavioral Pediatrics at the American Board of Pediatrics and is on the Board of Directors of the Society of Developmental and Behavioral Pediatrics. She is also on the American Academy of Pediatrics planning committee for Practical Pediatrics, their national CME Program.
Deborah Frank, MD
Dr. Frank is the Director of the Grow Clinic for Children and a board-certified Developmental and Behavioral Pediatrician at Boston Medical Center (BMC). She is also a Professor of Pediatrics at Boston University School of Medicine. Dr. Frank attended Harvard Medical School and completed her residency at Children's Hospital Seattle. After her residency, she went on to complete a fellowship in Child Development at Children's Hospital Boston. Dr. Frank specializes in issues of growth and nutrition and the impact of hunger on child development.
Dr. Frank has written numerous scientific articles and papers. Her work has focused on breastfeeding promotion, women and children affected by substance use, nutrition among homeless pregnant women and children, Failure to Thrive, food insecurity, and the “heat or eat” phenomenon, the dilemma that many low-income families face in the winter when they have to make the critical choice between heating their homes and feeding their children. She is especially proud of successfully mentoring many pre-professional and professional colleagues.
Cited as a respected authority in her fields, Dr. Frank has frequently given testimony to state and federal legislative committees on the growing problem of hunger and associated hardships in the United States and its effects on our youngest children. She has recently been nominated by Congresswoman Nancy Pelosi to the newly established National Commission on Hunger. She is also an invited member of the Aspen’s Dialogue on Food Insecurity and Health Care Costs.
L. Kari Hironaka MD, MPH
Dr. Hironaka is a board-certified Developmental and Behavioral Pediatrician at Boston Medical Center. She completed her fellowship at Boston Medical Center. Dr. Hironaka specializes in health services research, health literacy and ADHD, as well as residency training.
John Maypole, MD
Dr. Maypole completed Pediatric Residency in 1999, and Pediatric Chief Residency in 2000 following his training at Yale University School of Medicine. Dr. Maypole has consistently included primary care, medical education, and in participating in and developing innovative clinical programs for complex children and their families. Dr. Maypole served as Associate Director of the Pediatric Integrative Medicine Education Project and performing Holistic Medicine consults and medical education at Children’s Hospital from 2003-2005. In 2005, Dr. Maypole became Director of the Department of Pediatrics at the South End Community Health Center while serving as an attending physician for the Comprehensive Care Program (CCP) in the Department of Pediatrics at Boston Medical Center. CCP is a multi-disciplinary team of providers who provide enhanced and coordinated primary care to the most medically complex patients and higher risk families in the Pediatric Department, including ex-premature infants, children with special health needs and neurodevelopmental disabilities. In February of 2013, Dr. Maypole came to Boston University/Boston Medical Center to work full time to develop approaches and programs to address this fast-growing segment of the pediatric population. In September of 2014, Dr. Maypole received an award from the Center for Medicare Medicaid Innovation, supporting a 3 year effort for the Massachusetts Alliance for Complex Care/4C program--a consultative, multidisciplinary care support model of care for PCPs and families of medically complex children, of which he is co-principal investigator. He is an associate professor of Pediatrics at BUSM. Dr. Maypole writes child health-related articles for a lay audience, for mainstream media and online publications.
Jenny Radesky, MD
Dr. Radesky is a board-eligible Developmental Behavioral Pediatrician and a board-certified general pediatrician who recently joined the faculty at Boston Medical Center after completing her fellowship training here. She attended Harvard Medical School and completed her pediatrics training at Seattle Children’s Hospital. Dr. Radesky is a clinician-investigator whose clinical interests include early childhood adversity, attachment relationships, and child self-regulation, as well as teaching trainees methods of observing parent-child interaction. Her research examines mobile/interactive media use by parents and young children and how this effects parent-child interaction and child social-emotional development. She is an active member of the AAP Council on Communications and Media.
Arathi Reddy, DO
Dr. Reddy is a board-certified Developmental and Behavioral Pediatrician at Boston Medical Center. She attended medical school at Western University of Allied Health Sciences in Pomona, CA and completed her residency at Morristown Memorial Hospital/ University of Medicine and Dentistry of New Jersey in Morristown, NJ. She completed her fellowship at Einstein Montefiore and worked in NYC prior to joining the faculty in March 2011.
Jodi Santosuosso, NP, MSN
Jodi is a certified nurse practitioner in the Developmental and Behavioral Pediatrics Division at Boston Medical Center. She attended University of Massachusetts College of Nursing and Health Sciences and completed her residency at University of Massachusetts, Boston. She joined the Boston Medical Center and Boston University School of Medicine faculty in April 2007. Jodi has had extensive training in developmental and behavioral pediatrics, gastrointestinal (GI) diseases and ear, nose and throat (ENT) disorders.
Laura Sices, MD, MSDr. Sices is a board-certified Developmental and Behavioral Pediatrician at Boston Medical Center (BMC). She attended medical school at University of Pennsylvania in Philadelphia, PA, completed her residency at The Children's Hospital of Philadelphia and completed her fellowship at University of Washington in Seattle, WA. Dr. Sices was on the faculty at Rainbow Babies and Children’s Hospital in Cleveland, OH before joining BMC in 2007. Dr. Sices’ clinical work focuses on assessment and management of children with a variety of different concerns, including developmental delays, speech and language delays and conditions, ADHD, learning disabilities and differences, and autism spectrum conditions. Her academic focus is on developmental screening and the early identification of developmental delays.
Naomi Steiner, MD
Dr. Steiner is the Director of Training at the Division of Developmental and Behavioral Pediatrics. Dr. Steiner studies how computers train the brain, which is an area of great interest in overlapping fields of ADHD, psychology, neuroscience and education, and closely followed by many as a complimentary or alternative approach to the traditional psychopharmacological treatment of ADHD. She is specifically interested in implementing neurofeedback attention training in schools. She is also interested in teaching self-regulation skills and relaxation breathing in schools. Dr. Steiner is multicultural and multilingual. In 2030 more than 50% of children will be raised bilingual in the United States! Dr. Steiner has written a book on how to successfully raise children bilingual (7 Steps to Raising a Bilingual Child), and instructs medical professional, teachers and parents on how children learn two languages, and how English Language Learners can be successful at school.
Mary Ellen Stolecki, NP, MSN
Mary Ellen is a board certified pediatric nurse practitioner in the Developmental and Behavioral Pediatrics Division at Boston Medical Center and an Instructor of Pediatrics at Boston University School of Medicine.
She specializes in primary care of the Child with Special Health Care Needs (CSHCN) in the Comprehensive Care Program. She also practices in the Pediatric Gastroenterology Division providing specialty care for gastrointestinal (GI) conditions.
Her clinical interests are primary care for medically complex children (as well as GI issues) of CSHCN including: care of the premature infant, autism, cerebral palsy, seizures, Down syndrome, Williams syndrome, Turner syndrome,achrondroplasia,and multiple congenital anomalies.
Jodi Wenger, MD
Jodi Wenger, MD is a graduate of Dartmouth Medical School who completed her pediatric residency at Boston Medical Center. She spent several years on the Navajo Reservation in northeastern Arizona before transitioning back to Dartmouth Hitchcock Medical Center in Lebanon, NH. She served as a pediatric hospitalist, outpatient provider and educator at Dartmouth Medical School.
She has always had an interest in children with special health care needs. She worked in the Comprehensive Care Program at BMC as a resident and is thrilled to return. She was the general pediatrician at the multidisciplinary spina bifida clinic at Dartmouth Hitchcock and cared for children with neurologic challenges while on the Navajo Reservation.
Dr. Wenger has also had an interest in resident work hour reform and continues to support the software she and her husband created during her chief resident year. Amion, continues to allow one to make fair physician call schedules that can be easily accessed online.
Barry Zuckerman, MD
Dr. Zuckerman is Professor and Chair Emeritus of Pediatrics at Boston University School of Medicine/Boston Medical Center. He is a national and international leader in child health and development. His research focuses on the interplay among biological, social and psychological factors as they contribute to children's health and development. Dr. Zuckerman and colleagues have developed four programs that transformed health care to better meet the needs of low income and minority children. The success of these efforts is that they are now all national programs; Reach Out and Read, Medical-Legal Partnership, Health Leads and Healthy Steps. In addition to more than 250 scientific publications, he has edited nine books, including three editions of Behavioral and Developmental Pediatrics: Handbook for Primary Care. He has served on prestigious national committees; National Commission on Children, Carnegie Commission on Young Children, Bright Futures, and has received numerous national and international awards including the C. Anderson Aldrich for Child Development and the Joseph St Geme Award for Leadership from AAP, and the Policy and Advocacy award and Health Care Delivery Award from the APA. He has consulted in Turkey, Bangladesh, and Thailand regarding child development.
- See more at: http://www.bmc.org/pediatrics-developmentalbehavioral/team.htm#sthash.UrLgPWRv.dpuf
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