Greg Fritz, MD: Welcome to MindCast, Healthy Mind, Healthy Child, a podcast from the experts in children's mental health from Bradley Hospital.

I'm your host, Dr. Greg Fritz, and I'm here today with my co-host, Dr. Tanuja Gandhi. We are thrilled to be here today with a sequel podcast. Kristen Kichekfski, Chief Nursing Officer at Bradley, joined us last year to talk about de-escalation strategies and she was on that podcast and that podcast was our most listened to episode to date. Congratulations. So, of course, we invited her back to dive deeper into this topic. Welcome back again, Kristen.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Thank you for having me. I'm very happy to be here.

Tanuja Gandhi, MD: Welcome, Kristen. I distinctly remember that episode. We talked about de-escalation strategies and I did learn a few tricks that we could use and I'm sure our listeners who might be a lot of parents and families taking care of little ones might have learned a few tricks to use in their home too. So very happy to have you back.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Thank you so much. Well, let's go ahead and get started. So just a reminder, de-escalation is defined as helping someone process difficult emotions. And we want to do this, of course, without causing harm. So last time we spoke, we concentrated on recognizing the signs of escalation and the importance of really meeting someone where they're at.

The best way of de-escalating a situation is really finding out what's going on with them and helping them cope with that and bringing them back down to where they need to be.

Greg Fritz, MD: Right, so let's start with the basics. Can you please help our listeners recognize what escalation looks like in children?

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Absolutely. So, real briefly, we want to look for some warning signs. It could be a child starting to get frustrated over something that wouldn't normally frustrate them. It could be that thing that we talked about last time called HALT. You know, are they hungry? Are they angry? Are they lonely? Are they tired? They could be seeking attention more, they could be trying to be alone more, and it's really important to know what an individual's patterns are within themselves.

Tanuja Gandhi, MD: So how can parents recognize these signs in their own children, especially when emotions run high? For example, the children are escalated, escalation defined by the terms you're mentioning, or when parents themselves have emotions running high in that situation.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Yeah. So, you know, it's really important to look for patterns and understand what different nonverbal cues are. And you really want to really think about what your patterns are within yourself and then recognize what those patterns are for your children. And so, really pay attention. Know your kid, know yourself.

So, you know, for your child, do their faces turn red? Are they wringing their hands? Are they shaking their fists? Are they patient? Are they interrupting people? Really kind of looking to see what that looks like and kind of intervening early. Also know yourself. Are you getting impatient? Is your blood pressure going up? Are you starting to think like, Oh my gosh, what's going on? Like, you know, and you know, are you responding differently? Recognizing it within yourself is almost just as important as recognizing it with your child.

Greg Fritz, MD: So using those cues, whether they're your own or your child's cues, what are some early steps that the parent can take to start the de-escalation and prevent it from getting worse?

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Yeah, absolutely. That is the key, right? You know, recognizing it and, in yourself, and we really want to stop. And the first thing I always say is just stay calm. Remember, you want to avoid a power struggle, use that stop and halt framework. You want to validate emotions and actively listen, you know, don't react immediately.

Try to understand, you know, what are they saying to me? What's going on? Because a lot of times what they're responding to and what they're escalating about is something that they may not be saying out loud. It might be something that you have no idea what the underlying problem is or it could be, something that you don't really think is a big deal, but to this four, five, six year old, it's the end of the world, and you really want to see it from their eyes.

Tanuja Gandhi, MD: That's so pertinent and thoughtful. You mentioned that de-escalation also helps teach important life skills. And I'm sure, when you're trying to meet the child or teenager where they're at, and you're trying to listen carefully, having a loud, high pitched, angry voice while you're doing that really doesn't help.

So there's a lot of like voice modulation and tempering of affect that parents have to do or the listener has to do when a child is escalated. So going back to my question, what kind of life skills you think this kind of de-escalation teaches us? And could you explain how that works?

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Absolutely. When we're de-escalating or we're helping a child work through different problems in different ways, how we do it actually not only helps them learn the skills of how to self-regulate and work through a complex problem, but we're also really demonstrating how they can use empathy, how they can compromise, how they can solve a problem.

So I'm sure everybody listening today listened to the last podcast we did. And, you know, we talked about the bedtime story and, you know, where the dad was reading a bedtime story, the same story over and over again that the child wanted, and they kind of got a little tired of it, and they wanted to read something else, and the child was escalating, and they finally realized they were in a power struggle loop, and so they read the story that the child was asking for, and they de-escalated. Well, and that's great, and that was perfect, and avoided the power struggle, but what if, we change it up a little bit, and, you know, the child's escalating, and the father says, you know what, that book's really important to you.

We're going to read that book, but this other book I really like, and I think you'd like it too. So let's read the book you really like tonight, and tomorrow night, I'd like to read this other book to you that I really like. What do you think about that? So now you've done two things, right? You've de-escalated the situation, and you've modeled compromise.

And compromise is a very important life skill that they're going to need when they get into school. That's going to carry them through friendships, and that's really going to be a foundational block.

Greg Fritz, MD: So where does praise come in and positive reinforcement for when something is going well? Talk about that a little bit.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Absolutely. Praise has two roles. Praise has a daily role and praise has a role in de-escalation. So praise as a daily function really helps build confidence and really helps kids kind of build that resilience. It's really kind of a preventative medicine for escalations, and then praise within the moment of escalation can really help redirect attention, acknowledge someone's effort as they're trying to calm down, and really build trust.

But there's a key to it. It has to be genuine. It has to be genuine praise. They have to feel it. And you want to praise even the smallest successes during an escalation event. You know, they're screaming, they're yelling, and maybe you drop something and they pick it up and they hand it to you. And you're like, oh my gosh, thank you.

I needed that. Cool. You know, I mean, just no matter how small it is, any little praise to redirect that attention, is going to be very important and give them some sort of positive feeling while they're working through that negative.

Tanuja Gandhi, MD: Thank you for that. Praise is such an important part of our lives that we often don't remember to do it. And I think everybody, is susceptible to a little bit of praise, right, be it children or adults. Now, another thing that comes up with escalation, de-escalation discussions, is that children themselves sometimes describe their behaviors as acting out, because adults do that too.

Recently I had a kid, who had a really significant episode of being dysregulated and upset and aggressive. And in our conversation, the child was like, yeah, you know, sometimes when I act out, and I was struck by the fact that the child has accepted their behavior as acting out. I'm sure there are times when children are acting out.

But can we speak to this a little bit, as to what parents can do and how they could describe these behaviors and other terms that can be used instead of labeling everything as acting out?

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Yeah, absolutely. I think one of the first things that we really need to do is understand that behavior is often reflecting unmet needs.

And those unmet needs may be expressing an underdeveloped language skill. You know, they may be really that acting out may not be a willful or manipulative or some sort of like intentional behavior. They may not be able to control it. You know, maybe they have some sort of internal motor, or maybe they're trying to like get some sort of energy or message out.

They might not be able to express their thoughts in words. And so they're trying to get their message across in another way. It's important to look for patterns and understand the meanings behind actions. And so sometimes when a child at a certain time is doing the same thing over and over again, that might represent something.

And so we always want to kind of look for those trends and patterns and really try to understand what they're experiencing and what they might need help learning to work through.

Greg Fritz, MD: I have to say, I think when either children or parents use mental health jargon, like acting out, it's a sign that it's not genuine. I mean, I think, your kid who said that, that's really painful to hear that.

Tanuja Gandhi, MD: That yeah.

Greg Fritz, MD: It means they've been too much in a psych setting and exposed to jargon that is, no kid says acting out, really, and parents shouldn't be either, in my opinion.

Tanuja Gandhi, MD: So, this child did mention acting out, and there are many times when children mention that word but have not been in psychiatric settings. I think in general, when children are having behavioral problems or are expressing needs through behaviors, like Kristen, you mentioned, there is this tendency, for a lot of adults to say, oh my God, it's a temper tantrum, or it's an acting out kind of phenomenon.

And it can be that in some settings or some situations, but it's not always that. That's basically what we're trying to highlight and discuss over here. And then ways de-escalate the child instead of using a term, which then gets carried on for every behavior, without addressing the underlying emotion.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Yeah. And people really look at different situations. They could label them as acting out and it really is a child expressing a completely different emotion that they don't even know they're having. So something that we all may have seen, at some point, somewhere. Right? And I know we see this here because we have a basketball court. Some of you may see this in your driveways or on the schoolyard, but picture this; we have some kids playing a fun pickup game of basketball and they're all having a good time. And one yells, that was a foul. And the other one says, no, it wasn't. And now all the kids are yelling at each other. Right? Who hasn't been there? And suddenly the first kid is now crying, saying, this always happens. Nobody ever likes me. Nobody ever sides with me and everyone always cheats. And they grab the basketball and they run off the court and they sit in the corner and they start crying. And now everybody's standing around without a basketball, staring at them. And we've got a kid in the corner, holding a basketball, crying.

So, like, what do you do? Someone could say, well, they're just acting out. They stole the ball. They're just doing this again. They're having a temper tantrum. Or, do we go, we recognize that this isn't acting out. It's not about the foul. We're going to go, we're going to sit down, we're going to listen to them quietly, we're going to ask them questions, we're going to let them talk, we're going to offer praise when possible.

Maybe we ask them to give the basketball back so the others can keep playing. And we say, that was awesome. Thank you. You know, and maybe we help them some feelings. And maybe we hear that earlier that day, they were asked a question in front of the same group of kids. They didn't know the answer and they got really embarrassed.

And they felt like everybody was staring at them. And that's really what's happening, and we get a chance to help them work through that. And we would have never known if we just labeled them as acting out.

Tanuja Gandhi, MD: Right.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: So I mean, we're missing moments when we don't explore.

Greg Fritz, MD: So it really is fascinating how often we expect kids to manage emotions in ways that even adults struggle with. I mean, that example is one of them. Could you talk a little bit about this gap in expectations between what a kid's capacity is and what we tend to expect?

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Yeah, I mean, absolutely. So we talked about this a little bit last time, right? So as adults, when we're upset, what do we want? We want to be listened to. We want to talk to someone. We want to be heard, right? We might call up a friend. We might stop by someone's office that we know is going to listen to us and go, yeah, you know, I mean, we, really kind of like it when people agree with us, right? We want to be respected. We want to get our point across. We kind of like it when some people are around us sometimes, you know? And we want to be heard. And if we're agreed with, that's even better. On the other hand, when kids get upset, what do we do sometimes? We seem to want them to listen to the adult.

We want them to stop crying. We want them to stop yelling. Speak nicely. Don't talk back. Listen to me. No, I need you to do what I'm saying, why don't you go to your room until you calm down. No, just go alone and think about this. We're asking them to do things that we wouldn't do ourselves.

And then we're wondering why they're escalating. This is the opposite of what we know works for us. And we're asking the child to do it. So we're asking them to do more, we're expecting them to do more than what is realistic for A, ourselves, and B, for them and their developmental level, instead of listening to them and helping them through it.

Tanuja Gandhi, MD: I think the key point is the age and developmental level of the child, because you can't have the same expectations of a 5 or an 8 year old as you would have a 15 year old.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Exactly.

Tanuja Gandhi, MD: So when I say 8 and 15, it becomes more obvious. But if you say 10 year old and a 13 or 14, it's much closer together. But developmentally, they're still at very different stages. So the things they can do, can understand are so different compared to what we think they understand. Because, you know, a lot of times parents or even caregivers will be like, oh, I know the kid gets it. They're being manipulative. And there might be instances when that's happening.

Everybody, you know, has behaviors and children sometimes have behaviors to get their needs met. Sometimes positive, sometimes negative, but not all situations are the same and they don't always get it. So speaking to that again, going back to a point you made earlier about parents being active listeners and being present with the kid, what if they are upset, right? So how can parents use mindfulness for themselves to stay grounded and model the emotional regulation piece that we're talking about?

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: That's a great, great question. There's some really, really simple ones. There's some breathing exercises. Just do some deep breathing. Focus on your breathing. Maybe close your eyes. Do some deep breaths. Not when you're driving. Don't close your eyes. You can do the deep breaths. But, maybe, some grounding techniques.

Pick four things in the room to look at. Obviously when you're alone, not with your child, focus on your child, not your phone, but there's some really great apps on your phone that can really help you, teach you meditation techniques, teach you some grounding techniques.

If you're not familiar with it, use resources that you have, but really try to focus on centering yourself and really trying to remember it's not about me, it's about them. It's not about me, it's about them. They're not yelling at me, they're yelling at their toy, you know, or whatever it is, you know, but it really, there are some really great tips that parents can use to stay grounded and model that emotional regulation.

You know, deep breathing, take some deep breaths, deep breaths, close your eyes, really be present in the moment and allow yourself to focus on what is happening and what you're hearing. Another great grounding technique that I love is picking four items in the room to look at. Really kind of focus your eyesight on different items and take those deep breaths.

There's also, you know, and of course, not when your child's in the room, but when you're alone, there's some great apps that are out there that can teach you different mindfulness techniques. And I really encourage people to use those because this isn't intuitive to a lot of people. And so, you know, go find one that really works for yourself and really just practice, you know, when you have time to yourself, you know, who knows what that is, but when you do have some time, practice these mindfulness techniques and then share them with your children and do them together to help them build that skill.

Tanuja Gandhi, MD: So we covered a lot of topics today, right? So let me summarize the key points and tell me if I'm missing anything. We talked about recognizing patterns of escalating behaviors, which includes frequent episodes of say, yelling, screaming, looking physically upset. Sometimes kids are throwing things. Sometimes they're making a fist, the voice is loud, and the kid basically looks upset. So these are all signs of escalating behaviors.

And sometimes there's a pattern around it when children are getting upset more often. And the strategies for de-escalation that we talked about are basically meeting the child where they're at and remembering that not all strategies work for all kids and you have to tailor it based on your child or the child in your care, their age and stage of development, and to the situation.

And most importantly, while we're using de-escalation strategies, to make sure we are checking in with ourselves and using as calm a voice and tone as possible, being supportive and being open to listening, offering praise. And maintaining that supportive stance afterwards because I remember from some of our previous episodes that what a strategy we discussed is what comes after de-escalation is doing repair work.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Yes, absolutely. We can never forget the repair work and it's an important part of closing that circle.

Tanuja Gandhi, MD: And then when, you know, when you've successfully de-escalated the child or your child, the power you feel in the situation helps you reinforce those strategies that worked and then use them over and over again to then change that behavior pattern. Does it summarize all the key points?

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Perfectly.

Tanuja Gandhi, MD: Oh, wonderful. Thank you.

Greg Fritz, MD: That's a lot of ground. We've covered a lot of ground today, I think. And it could be overwhelming, but I think that what the listeners should do is think about trying one new strategy in the next week or something and, picking something that really resonated from this conversation to what they're dealing with or their approaches and see what happens.

Kristen Kichekfski, DNP, MBA, RN, PMH-BC, N: Exactly. I love it. Well, you know, small changes really can make big differences, and I really hope people take that advice. Thank you guys so much for having me again. This was a lot of fun.

Greg Fritz, MD: Well, thank you for being here. And if the listeners would like to check out our podcast library, we urge you to visit bradleyhospital.org/podcast. Thanks for listening.