If a child falls off a bike and gets hurt, and then cries and throws the bike in frustration, most adults wouldn’t then punish the child and take the bike away.

But children in residential facilities who are suffering from emotional pain – which may not be visible or obvious – are sometimes punished for screaming, crying or throwing things.

A model of care for children’s residential agencies, developed over nearly 15 years by the Residential Child Care Project at Cornell, takes children’s emotional pain into account and emphasizes the bond between the children and their caregivers. In a four-year study at 13 facilities, the Children and Residential Experiences (CARE) model reduced behavioral incidents and, according to surveys of children and adolescents living in these facilities, improved their relationships with caregivers.

“No child should be punished for behavior that is a result of pain – either physical or emotional. That is inflicting pain on top of the pain they already feel, which only increases the damage,” the researchers wrote in “An Evidence-Based Program Model for Facilitating Therapeutic Responses to Pain-Based Behavior in Residential Care,” published in the International Journal of Child, Youth and Family Studies.

“The ability to deal with children’s psycho-emotional pain without inflicting additional painful experiences on them is one of the biggest challenges for caregivers and therapeutic residential care,” the authors wrote.

Most children and young people in residential programs have had traumatic experiences such as severe loss, neglect, rejection and abuse, but many agencies lack a comprehensive vision of how to help the children change and grow, according to the article. Co-authors were Martha Holden, project director of the Residential Child Care Project at the College of Human Ecology’s Bronfenbrenner Center for Translational Research, and Deborah Sellers, the project’s director of research.

To develop the CARE model, the team explored existing studies about the effects of trauma on children, and strategies that have been proven effective in dealing with it.

“We’ve built trauma-informed strategies into this program, as well as directions for how to interact on a daily basis with the children, to help them develop different ways of responding when they’re angry or afraid,” Holden said. “If you don’t have a unified theory of change, and most agencies don’t, everyone goes in and works with the children based largely on the way they were raised, or raised their own children.”

CARE reorients agency practices around six core principles to produce programming that is:

• based on relationships between children and caregivers; 
• informed by the trauma children have likely endured; 
• targeted at each child's developmental stage and needs; 
• family oriented; 
• focused on allowing children to develop their own competence; and 
• open to adapting their environments to support the children's success.

CARE consultants work with agency leaders on how best to incorporate these principles in their organization's policies, procedures and practices. The process generally takes three to four years.

“You have to shift mindsets,” Holden said. “You basically have to embed it in the culture of the organizations: This is who we are; this is how we interact with children and families.”

In the four-year study of the CARE model, funded by the Duke Foundation, 13 agencies in North Carolina showed decreases of 3% to 5% per month in incidents of aggression toward staff, property destruction and running away. Children’s perceptions of the quality of their relationships with caregivers, gauged via surveys, improved by 8% to 14%.

In interviews, Holden said, staff members trained in the CARE model said they wouldn’t want to return to their former methods.

“It doesn’t make the work easier – it’s always hard work – but it makes it so much better,” Holden said. “People are having fun with kids again. It’s not just dealing with bad things, it’s feeling like you’re helping children grow and develop and thrive, and you’re doing it in conjunction with other staff members with the same mindset.”

Other studies of the CARE model are being conducted in New York and Connecticut. In 2017, the California Evidence-Based Clearinghouse rated it as evidence-based with promising research evidence. 

Part of the reason for the model’s apparent success, Holden said, is the collaborative way the team has worked with agencies to implement CARE.

 “Sometimes you have problems taking models that have done well under research conditions and putting them in a real-world setting. This is starting in a real-world setting,” she said. “It really does feel like a true partnership, because it fits what the agencies do.”