Dennis Alters, M.D.

“The Wizard’s Way is a novel approach that combines anger management and social skills training. It involves children in a unit fantasy that promotes self-control while retaining and promoting a child's interest.”¹

Journal of the American Academy of Child and Adolescent Psychiatry (2002), 41 (suppl) 12s.

In order to address in-patient management difficulties, a program was developed in 1990 to effectively reduce the need for seclusion and restraint. This article expands on its brief description in AACAP’s Practice Parameters for the Prevention and Management of Aggressive Behavior.¹

This carefully designed program entices children and young teens into the therapeutic milieu. There was a 90% decrease in the use of seclusion and restraint in the first in-patient facility. Kluner cited a 50% decrease in the second.² The program both reduces the frequency and de-escalates potential crisis. Training and programming increase the staff skills and sensitivity.

The first step is a feasibility study to assess the facility’s behavior management culture, therapeutic and crisis models. Various instruction models are offered from “training the trainer” to the full in-house staff. Staff training is multimodal to accommodate individual learning preferences, on-going support and program reassessments facilitate the implementation of goals.

Imagine: 11-year-old Johnny angrily exited the family session. Johnny’s outstretched hands paused short of grabbing an unsuspecting boy by the neck. Instead, he threw an empty chair to the floor. The staff arrived shortly after the crash.

Johnny responded by walking over to the eye-catching map of Wizard’s Way. He moved his skateboarder game piece from the rewards path to a penalty zone. Johnny announced, “I am in the Volcano of Temper and headed to The Ice Dunes of Danger!”

A staff member who serves as his Guide calmly informed him, “Let’s talk about what happened and maybe you can get back on the path.” Johnny related, “I hate it when my sister calls me a dork and no one does anything.” The Guide responded, “Let’s go on a Smugwamp hunt together. You are having a Smugwamp kind of day.” Johnny was startled. “But don’t you get a reward for doing that? I was mean. I was going to choke Billy and I threw a chair.”

They got out the Wizard’s Way workbook to complete the challenge of the Smugwamp. Johnny intently drew his two-headed purple and green name-calling Smugwamp monster that steals good moods. He listed three triggers that make his Smugwamp appear and three activities that could make it go away and feel better. The situation calmed. The staff processed his feelings including assertive training. Johnny was acknowledged for not hurting his peer. Wizard’s Way would reward him for implementing the three positive activities.

Current treatment models don't anticipate. This creates reactionary system responses. The inherent risk to the minor and staff during “takedowns” are numerous.^1,3,4,5 Programs create appropriate responses only after a crisis. This rewards crisis.

Level 1 interventions are skill based techniques to “increase the patient’s behavioral self control and encourage self determination, while preserving the safety of the patient, others, and property."¹ Program protocols were designed to have an intuitive intrinsic emotional meaning to the child. Language is used symbolically to address treatment in a multimodal, multisensory fashion and takes into account the analogues of children’s communication.⁶ Preoperational and operationally based exercises utilize peak performance, sociometrics, and conflict resolution, with cognitive, behavioral, dynamic, art, psychodrama, conflict resolution and music therapies.

There are over 300 DSM coded maturationally sensitive skill-building interventions matched to developmental levels and diagnosis. These range from mild to intense, positive to restrictive, and structural to insightful. Wizard’s Way is effective with all major and minor psychiatric disorders except for severe autism and severe mental retardation. This broad scope in playful format reduces stigma. To reinforce internal positive change, the program transitions with maturational development from staff rating to a selfrating system.

The interventions are clear and positive. Children gain a deeper understanding of problems and retention of coping skills. They are readily able to identify and assert needs and feelings. This builds a sense of mastery. Parents and children are less anxious in this milieu. There was improved consumer response.²

It is critical that intervention reaches kids on their level and motivates change in an upbeat fashion. Although our program presents itself as a fun fantasy adventure, the interventions are cleverly cloaked high-powered standards of care made child friendly. It is not only a fun adventure. Skillbuilding exercises are coordinated to different DSM coded levels of difficulty. The staff becomes a guide for the patient on this journey. This shifts the paradigm. Patients now perceive the clinician and staff as mentors and not adversaries. Kluner and Morrey reported a boost in staff morale. ² The program was designed to be clear and simple so neophyte or non-clinical staff or per diems can administer it. Satirz reported easy, cost effective, and turnkey user-friendly implementation.² It is also important Alters from page 158 that any program provide seamless record keeping for clinical progress, research and QA. We designed our program to be effective with all major and minor psychiatric disorders except for severe autism and severe mental retardation. This broad scope, combined with a playful format, reduces stigma because all kids are enjoying the same game.^2,7,8,9,10

It is important that any intervention program transitions smoothly to outpatient settings creating a multitiered levels of care.² This ensures continuity of care and longer lasting results. Compatible applications should be available for the school, home, outpatient therapist office, group and foster homes, residential, partial day program, and community settings.

It is also important that any program transition from an external or program administrator reward system to an internal or self-rating system. Patients can learn to reasonably and reliably reward themselves, with less adult management, for an internalization of positive change.^2,7,8,9,10

Dr. Alters practices child and adolescent psychiatry in Oceanside, CA. He is a member of AACAP’s Continuum of Care Committee. Individuals interested in learning more about Dr. Alters’ program, Wizard’s Way or Level 1 Program Consultation, can contact him by email at dr.alterswizardsway@att.net or phone at 760.967.5898.

References
(1) American Academy of Child and Adolescent Psychiatry (2002), Practice Parameters for the Prevention and Management of Aggressive Behavior in Child and Adolescent Psychiatric Institutions with Special Reference to Seclusion and Restraint. J Am Acad Child and Adoles Psychiatry 41 (suppl) 4s-25s.

(2) Alters DB, (1998) Wizard’s Way Introductory Video. Oceanside, CA: Wizard’s Way Publications (personal communication documentary available upon request)

(3) Masters KJ (2002) Making the Case for Locked Seclusion, AACAP News 6: 294.

(4) Wadeson H, Carpenter W (1976), Impact of the Seclusion Room Experience. J Nerv Men Dis 163: 318 – 328.

(5) Devitt CK, Seclusion and Restraint: The “One Hour Rule,” AACAP News 5: 219.

(6) Trad PV (1992), Use of developmental principles to decipher the narrative of preschool children. J Am Acad Child and Adoles Psychiatry 31 (4): 581-92.

(7) Alters, DB, Wizard’s Way®: New Ways in Child and Adolescent Therapy, Chair of Multimedia Workshop, 2000 American Psychiatric Association Institute Scientific Proceedings, Philadelphia, PA, 2000.

(8) Alters, DB, Wizard’s Way®: Community Mental Health Intervention for Children and Adolescents, Chair of Multimedia Workshop, 1999 American Psychiatric Association Institute Scientific Proceedings, New Orleans, LA, 1999.

(9) Alters, DB, Cartoons, Quality and Managed Care, WIZARD’S WAY®: Demonstrating Child Therapy, Chair of Workshop, 1995 American Psychiatric Association Scientific Proceedings, Miami, FL 1995.

(10) Alters, DB, Cartoons, Quality and Managed Care, Introducing WIZARD’S WAY® to the Child Psychiatrist in Residential Care Programs, Chair of Workshop, 1994 California Psychiatric Association Scientific Proceedings, La Jolla, CA 1994.